Resident Left Unattended with Medication Leading to Fall
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including congestive heart disease, anxiety, and Type 2 diabetes mellitus, was left unattended with a partially administered dose of sodium polystyrene sulfonate mixture. The resident required extensive assistance with activities of daily living due to recent hospitalization, fatigue, activity intolerance, and confusion. During a medication pass, an LPN administered half of the resident's medications and, upon the resident's request for more applesauce, took the remaining pills to the medication cart but left the half-filled cup of sodium polystyrene sulfonate mixture on the bedside table in front of the resident. Shortly after, the LPN heard a noise and found the resident lying on the floor with wet marks on their clothing, and the resident reported vomiting after consuming the liquid medication. The LPN later acknowledged that the medication should not have been left unattended and was unsure if the resident had consumed the remaining mixture before the fall. Facility policy and the DON confirmed that staff are required to observe residents taking their medications in full before leaving them or their room, and the policy directs staff to observe resident consumption of medication.