Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of care for medication administration on two skilled units (2NW and 2NS). Medications were observed left unattended in resident rooms on these units. The DON confirmed that, within the past three months, there were two separate incidents where medications were left unattended—one on each unit. These incidents were also corroborated by social media posts alleging that medications were left at bedside, which prompted internal audits and further investigation. The facility's policy requires that medications be administered at the time they are prepared and that residents are observed to ensure the dose is ingested, but these procedures were not followed in the cited incidents. The deficiency was identified through staff interviews, observation, and review of facility documentation. The DON and administrator acknowledged the incidents and confirmed that the nurses involved did not adhere to the established medication administration protocols. No specific residents or their medical conditions were identified in the report, and the incidents were not linked to any particular patient outcomes. The deficiency was cited as past non-compliance, with no unattended medications observed during the current survey.