Medications Left Unattended at Bedside for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure the clinical appropriateness and safety of self-administration of medications for a resident with multiple diagnoses, including heart failure, diabetes, and dysphagia. The resident's comprehensive assessment indicated moderately impaired cognition and a need for setup assistance with eating. Despite this, surveyors observed on multiple occasions that a medication cup containing three medications was left unattended on the resident's bedside table while the resident was either asleep or awake, with the resident unable to confirm if the medications were theirs or when they were brought in. Interviews with nursing staff revealed a lack of clarity and consistency in medication administration practices. One RN stated that medications for this resident were typically given with applesauce and could not verify the medications left at the bedside, nor how long they had been there. The RN also admitted to not routinely scanning the room for unattended medications during medication passes. The DON confirmed that leaving medications at the bedside was not the facility's expectation and emphasized adherence to the rights of medication administration. These observations and interviews demonstrated a failure to follow facility policy and regulatory requirements regarding safe medication administration.