Medications Left Unattended and Not Administered per Physician Orders
Penalty
Summary
A deficiency was identified when a nurse failed to administer medications to a resident according to physician orders and left multiple medication cups containing tablets and capsules on the resident's bedside table for the resident to take at her discretion. Observations revealed that the resident, who had a complex medical history including right below knee amputation, muscle weakness, bipolar disorder, acute kidney failure, and peripheral vascular disease, had several medication cups with pills on her bedside table. The resident stated that nurses routinely left her medications in this manner so she could take them when she wanted, and that all the medications present were from that morning. Further observations on a subsequent day found additional medication cups with pills left unattended in the resident's room while she was not present. Interviews with nursing staff, including LVNs and RNs, confirmed that the facility's expectation was for staff to observe residents taking their medications and not to leave medications unattended. Staff acknowledged that leaving medications in a resident's room without supervision was not in accordance with facility policy and could result in medications not being taken as ordered. A review of the facility's medication administration policy confirmed that medications are to be administered according to physician orders and documented immediately after administration. The facility was unable to provide documentation of in-service training or skills review forms related to oral medication administration prior to the survey exit.