Medications Left Unsecured and Unconsumed in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access, as required by professional standards. During observation, a resident was found in her room with two cups containing a total of seven pills left on her tray table, along with a nutritional supplement. The resident stated that staff usually waited with her to ensure she swallowed her medication, but on this occasion, the medication aide left the pills and supplement in the room and departed. The medications had been left there since the morning, and the resident was unsure of what all the pills were. Record review showed that the resident had multiple diagnoses, including paraplegia, diabetes, osteomyelitis, cognitive communication deficit, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, pruritis, and hypertension. The medication administration record indicated that all morning medications were marked as given by the medication aide. Interviews with the DON and the medication aide confirmed that the aide did not observe the resident taking all her medications, contrary to facility policy, which requires direct observation of medication consumption. This lapse resulted in medications being left unsecured and unconsumed in the resident's room.