Unsecured Medication Left at Bedside After Administration Refusal
Penalty
Summary
A deficiency occurred when a medication aide failed to ensure that a resident received their prescribed morning dose of Protonix, a medication used to treat GERD. The medication was left in an unlabeled, unsecured cup on the resident's bedside table for several hours after the resident declined to take it during the morning medication pass. The resident, who had diagnoses including Parkinson's disease, type II diabetes, a history of fracture, GERD, and chronic pulmonary embolism, was cognitively intact and able to make himself understood. Facility records indicated that the resident required supervision or moderate assistance with most activities of daily living, but could independently reposition and transfer except for tub/shower transfers. Interviews with nursing staff confirmed that medications should not be left at the bedside and that any refused medication should be properly discarded. The medication aide responsible for the morning pass acknowledged not ensuring the resident took all medications and not removing the refused pill. The facility's policy required medications to be administered as ordered and within one hour of the prescribed time, and specified that only residents with physician approval could self-administer medications. However, the policy did not address leaving unlabeled medications at the bedside.