Medications Left Unattended with Non-Approved Resident
Penalty
Summary
A deficiency occurred when a resident, who was not approved to self-administer or safely store medications, was left with a cup containing eight pills to take independently. The resident's medical record indicated multiple diagnoses, including spinal stenosis, depression, diabetes, repeated falls, and other chronic conditions. An assessment had determined that the resident could only safely self-administer two specific medications, but there was no indication that the resident could safely store medications at the bedside, and no follow-up evaluations were completed with quarterly assessments. During a medication pass, an LPN prepared and placed eight different medications in a cup and handed it to the resident in their room, verified the resident had water, and then left the room while the resident began taking the pills. The LPN then returned to the medication cart, prepared medications for another resident, and subsequently left the unit, leaving the resident to finish taking the medications unsupervised. The resident confirmed that medications were sometimes left in the room for independent consumption and stated that some nurses allowed this because they trusted the resident to take them. The facility's list of residents approved for self-administration did not include this resident, and facility policy required quarterly reassessment of self-administration ability, which was not documented. The medications in question were ordered to be administered by clinical staff, not self-administered, and included high-risk medications such as antibiotics. The LPN confirmed the process of handing the medication cup to the resident and leaving the unit, despite the resident not being approved for self-administration.