Medication Left Unattended at Bedside Creates Accident Hazard
Penalty
Summary
A deficiency occurred when a resident with an intact cognitive status, as indicated by a BIMS score of 15, was found with two circular, white tablets on their bedside table during an observation. The resident had a history of a displaced intertrochanteric fracture of the right femur and was prescribed Acetaminophen Extra Strength, to be administered twice daily. Facility policy required that residents be assessed and documented as safe to self-administer medications before being allowed to do so, and that licensed nurses remain with residents while they take oral medications. However, there was no documented evidence that the resident had been assessed or approved for self-administration of medication. The Director of Nursing confirmed that medications should not have been left at the bedside and that the facility's responsibility was to ensure the environment was free from potential accident hazards. The medication was accessible to anyone entering the room, creating a potential for accidental consumption by individuals for whom the medication was not intended. The failure to follow established medication administration procedures and policies led to the deficiency.