Medications Left Unattended at Bedside for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a nurse left a medication cup containing both crushed and whole medications, including Protonix (Pantoprazole), on a resident's bedside table without supervision. The resident, who has dysphagia and no physician order for self-administration of medications, was left alone with the medications, and there was no nursing staff present in the room at the time of observation. Facility policy requires that medications be administered by licensed staff and remain under their direct observation or be locked away during medication passes. The incident was confirmed by the nurse assigned to the medication cart, who acknowledged that the medications should not have been left at the bedside. The observation revealed that the medication storage and administration practices did not align with the facility's policies or professional standards, as medications were not kept secure or under direct supervision. This deficiency has been cited in the facility's previous three recertification surveys.