Medications Left Unattended at Bedside
Penalty
Summary
Staff failed to ensure that medications were not left at the bedside for a resident with multiple complex medical conditions, including diabetes, chronic pain, and heart disease. The resident was observed to have two yellow tablets and a blue tablet in a medication cup on his bedside table, which he stated had been left by an agency nurse a couple of days prior. The resident indicated he kept the medications to take later if needed. Review of the resident's medical record showed active orders for oxycodone-acetaminophen and Tylenol Cold and Flu, but there was no physician order permitting medications to be left at the bedside. A Licensed Practical Nurse confirmed the presence of the medications in the resident's room, identifying them as two Tylenol Cold and Flu tablets and one oxycodone-acetaminophen tablet, the latter being a controlled substance. Facility policy required staff to remain with residents until all medications had been taken, which was not followed in this instance. The deficiency was identified through resident interview, observation, medical record review, staff interview, and policy review.