Unsupervised Medications and Unattended Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of three residents reviewed. Specifically, medications were left unsupervised at the bedsides of two residents, and there was no evidence that these residents had medical orders or had been assessed for their ability to safely and competently self-administer medications. In one instance, a resident with diagnoses including hypertension, atrial fibrillation, and heart failure, who was cognitively intact, accidentally ingested another resident's medications after a nurse left a medication cup at the bedside and left the room. The resident's care plan did not include goals or interventions related to self-administration, and there was no documentation of assessment or physician order for self-administration. In another case, a cognitively intact resident with osteoarthritis, rheumatoid arthritis, and chronic pain was observed with an unmarked medication cup containing topical cream left unattended on their tray table. The nurse confirmed that the resident applied the cream independently, but there was no care plan or assessment for self-administration in place. Additionally, an unlocked and unattended medication cart was observed in a common hallway. A nurse admitted to leaving the cart unlocked while attending to another room, acknowledging this was against facility policy. Interviews with facility leadership confirmed that staff are educated not to leave medications in resident rooms or leave medication carts unattended, but these practices continued to occur. The Director of Nursing noted that leaving medications unsupervised is a safety concern, especially given the presence of residents with mild dementia on the unit where these incidents occurred.