Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a nurse failed to remain with a resident during medication administration, contrary to the facility's policy requiring staff to stay with residents until all medications are taken. During an observation, a resident was found alone in bed with a medication cup containing nine pills left on the bedside table. The resident reported that the nurse left the medications at the bedside because she was not ready to take them, and the nurse did not remain to ensure the medications were ingested. The resident was cognitively intact but stated she did not know what all the medications were for, mentioning some were for nausea, dizziness, and high blood pressure. A review of the resident's electronic health record showed no evaluation for self-administration of medication had been completed, and the DON confirmed that the resident was not on a self-medication program. The DON also stated that medications should not be left at the bedside unless a resident is on such a program. The nurse involved reported that she assumed the resident would take the medications and left the room. This failure to follow professional standards and facility policy was identified through observation, interview, and record review.