Medications Left Unattended at Bedside Without Supervision
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure the complete administration of medications to a resident. The MA left a cup containing five medications at the bedside of a male resident with multiple chronic conditions, including type 2 diabetes mellitus, heart failure, chronic respiratory failure, generalized anxiety disorder, and major depressive disorder. The resident had an intact cognitive status, as indicated by a BIMS score of 15, and was prescribed pain medication, antidepressants, opioids, and hypoglycemics. The resident reported that the nurse left the medications on his table and that he had not taken them until after the surveyor's observation, at which point he ingested the pills in the presence of the surveyor. Upon interview, the MA confirmed that she left the medications in the resident's room without observing him take them, acknowledging that she was expected to remain with the resident until all medications were ingested. She recognized the risks associated with this action, including the possibility that the resident might not take the medications or that another resident could enter the room and ingest them, potentially leading to serious health consequences. The MA also stated that the resident did not have an order to self-administer medications and that she had previously received in-service training instructing her not to leave medications unattended. Further interviews with the Interim Director of Nurses and the Administrator confirmed that facility policy and their expectations required staff to observe residents taking their medications and not to leave medications in resident rooms. Both acknowledged the potential for harm if medications were not administered as intended. Review of the facility's medication administration policy indicated that medications should be administered safely and as prescribed, with proper documentation by the individual administering the medication.