Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when two unidentified pills were found on a resident's bedside table, despite the resident not being authorized to self-administer medications. The resident, who had a BIMS score indicating moderate cognitive impairment and diagnoses including type 2 diabetes, chronic kidney disease, and heart failure, was unaware of the pills' presence. The pills were discovered during an observation and interview, and the resident stated that he may have dropped them when taking his medication. The Wound Care nurse confirmed that medications should not be left at the bedside and removed the pills from the room. Further interviews revealed that the nurse responsible for administering the resident's medication had not noticed the pills on the left side of the bed and stated that she would have removed them if she had seen them. Facility policy requires that medications be administered directly to residents and observed to ensure ingestion, with any refusals documented and reported. The facility's policies also specify that medications must be stored securely and only accessed by authorized personnel. The presence of unsecured medication at the bedside was contrary to these protocols.