Unsecured Medications Left Unattended During Administration
Penalty
Summary
Medication Aide MA-B failed to properly secure medications for two residents during medication administration. For one resident, MA-B removed five blister-pack cards of medications from the medication cart, placed them on top of the cart, and after dispensing the required doses, left the remaining cards unsecured on the cart while entering the resident's room to administer the medications. The medications left unattended included Atorvastatin, Ropinirole, Levetiracetam, Prazosin, and Famotidine. The resident had a history of stroke, dementia, seizures, diabetes, hypertension, and hyperlipidemia, and was noted to have severely impaired cognition. A similar incident occurred with another resident, where MA-B removed four blister-pack cards of medications, placed them on top of the cart, and left them unsecured while administering medications in the resident's room. The medications included Amlodipine, Lisinopril, Metoprolol tartrate, and Potassium chloride. This resident also had a history of dementia, stroke, heart failure, hypertension, and chronic kidney disease, with severely impaired cognition. In both cases, MA-B locked the medication cart but failed to return the unused medication cards to the secured cart before leaving the area, resulting in the medications being left unattended and accessible. Interviews with MA-B, another medication aide, and the DON confirmed that medications should not be left unsecured and that only authorized personnel should have access to medications, as outlined in the facility's medication storage policy.