Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered for one resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. On the day of the incident, two white pills and one orange pill were observed in a medication cup on the resident's over-the-bed table at 10:35 AM, and the same pills remained there at 1:50 PM. The resident was unaware of the pills' presence, did not know what they were, and stated she was not going to take them due to ongoing nausea and recent vomiting. A registered nurse confirmed that the pills were two Reglan tablets and one Benadryl, which had been poured at 6:00 AM according to the medication administration record. The nurse stated she had not seen or left the pills at the bedside. The unit manager also stated that medications should not be left at the bedside and should be administered in the presence of a nurse. The facility's leadership team reviewed and acknowledged the findings, confirming that the medications were not administered as ordered and were improperly left at the resident's bedside.