Unattended Medication Administration and Lack of Supervision
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including heart failure, end stage renal disease, and hypertension, was found with a cup containing 13 pills left unattended at her bedside. The medications were intended for her morning dose, but the licensed nurse who administered them did not remain to supervise their consumption or verify that they were taken in a timely manner. The resident confirmed that the pills were her morning medications, and the state licensor was unable to determine the exact number of pills as they were not removed from the cup for counting. Review of the resident's Medication Administration Record showed that several medications, including blood pressure medications, anticoagulants, supplements, and pain medication, were documented as administered that morning by a registered nurse. The resident's care plan included interventions to administer medications as prescribed and monitor for side effects, particularly due to her risk for complications from anticoagulant and psychotropic medication use. Interviews with nursing staff and the Director of Nursing confirmed that the facility's standard practice was for the licensed nurse to observe residents taking their medications, especially for this resident who was known to doze off and forget to take her pills. It was also noted that some medications, such as Tylenol and Lanthanum Carbonate, were scheduled at specific times and could pose risks if not administered as directed. The Director of Nursing acknowledged that medication should not be left at the bedside unattended and that the nurse should have stayed to observe the resident taking the medication. The DON also stated that the timing of medication administration was important, particularly for medications with flex time ranges, and that leaving medication at the bedside made it difficult to determine when the resident actually took them. The facility did not provide specific education to nurses on this expectation, but it was considered a standard taught in nursing school. Reference materials cited in the report emphasized the importance of adhering to the rights of medication administration and timely delivery of scheduled medications.