Medications Left Unattended and Unsecured at Bedside
Penalty
Summary
Facility staff failed to follow professional standards of quality during medication administration for two residents. On the evening in question, an LPN prepared oral medications ahead of the scheduled administration time and left them unattended and unsecured at the bedside for two cognitively intact residents. The LPN did not observe one of the residents taking the prepared medications, and only later confirmed with the resident that the medications had been taken. For the other resident, the LPN found the medications still at the bedside later in the evening and then observed the resident taking them. Both residents had complex medical histories, including conditions such as diabetes, atrial fibrillation, chronic kidney disease, spinal stenosis, and hypertension. Interviews with the LPN revealed that the medications were prepared and left at the bedside to expedite the medication pass, despite the LPN's awareness that this practice was not permitted. Neither resident had been assessed for self-administration of medications, nor was there a physician's order or interdisciplinary team assessment indicating they were safe to self-administer. Facility policy required that medications be administered at the time they are prepared, not left unattended, and that residents be observed to ensure the dose is ingested. The facility's DON and staff development coordinator confirmed that the observed practices did not align with facility policy or professional standards.