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F0658
D

Medications Left Unattended at Bedside by LPN

Green Brook, New Jersey Survey Completed on 11-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse failed to administer medications according to acceptable standards of nursing practice for one resident. The resident, who had diagnoses including atherosclerosis of native arteries with ulceration, muscle weakness, and type 2 diabetes mellitus, was cognitively intact as indicated by a perfect BIMS score. On the date in question, the nurse left the resident's medications unattended at the bedside while searching for the resident's eyedrops, contrary to facility policy and standard nursing protocols. This action was confirmed by multiple staff interviews, including the nurse involved, the unit manager, and the director of nursing, all of whom stated that medications should never be left at the bedside under any circumstances. The facility's policy on medication administration requires that medications be administered safely, timely, and as prescribed, with nurses expected to verify resident identity, check orders, educate residents about their medications, and remain with the resident until the medication is taken. The nurse's deviation from this process by leaving medications at the bedside was identified as a failure to follow both facility policy and professional standards, as it prevented assurance that the resident actually took the medication as intended.

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