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F0658
D

Medications Left Unattended at Bedside

Los Angeles, California Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A medication cup containing pills was observed left unattended on the bedside table of a resident who had been admitted with diagnoses including hypertension, seizure disorder, and generalized muscle weakness. The resident's care plan required medications to be administered as ordered and for staff to monitor for effectiveness and side effects. The Minimum Data Set indicated the resident was cognitively intact but required moderate assistance with several activities of daily living, including set up with eating. On the morning of the incident, the resident confirmed that a licensed vocational nurse (LVN) had given her the medication but she had not yet taken it. Interviews with facility staff, including the restorative nursing assistant and the LVN involved, confirmed that the medication cup was left at the bedside and that the LVN did not remain with the resident to ensure the medication was taken. The director of nursing also confirmed that facility policy requires staff to remain with residents until all medications have been taken. Review of the facility's policy on administering oral medications reiterated this requirement.

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