Medications Left Unattended at Bedside by Nursing Staff
Penalty
Summary
Nursing staff failed to follow professional standards of practice by leaving medications at the bedside for four residents. Observations and interviews revealed that medications, including oxycodone and gabapentin, were left in cups on residents' tray tables without supervision. Residents reported that nurses sometimes left pills on their tables and did not always return to ensure the medications were taken. One nurse confirmed dropping off medications for a resident without staying to observe ingestion, and there was no order for self-administration for that resident. Facility policy required staff to remain with residents until all medications were taken. The residents involved had varying degrees of cognitive impairment and complex medical histories, including conditions such as ALS, diabetes, neuropathy, cerebral ischemia, chronic hepatitis, heart failure, chronic kidney disease, acute respiratory failure, dementia, and hyperlipidemia. Interviews with facility leadership confirmed that leaving medications at the bedside was not permitted and contradicted both facility policy and staff training.