Medications Left Unattended at Bedside Without Proper Assessment or Security
Penalty
Summary
Surveyors found that the facility failed to store all drugs and biologicals in locked compartments, as required, for two residents. Medications, including pill cups with multiple medications and respiratory treatments such as inhalers and nebulizer solutions, were observed left unattended at the bedside of both residents. Neither resident had a completed assessment for self-administration of medication, and their care plans did not address self-administration or the use of lock boxes for medication storage. One resident, with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and depression, was found with a pill cup of medications and respiratory treatments at her bedside. She reported that medication aides routinely left her medications for her to take without supervision and that she did not know what the medications were. The other resident, who was cognitively intact but had diagnoses including dementia and anxiety, was also found with an open pill cup containing several medications left on her bedside table. She stated that staff had left medications at her bedside multiple times without ensuring they were taken. Interviews with staff, including the DON and medication aides, confirmed that medications were sometimes left at residents' bedsides without supervision, and that there was no documentation of self-administration assessments for these residents. Facility policy required that medications be administered as prescribed and that staff observe residents taking their medications, but these procedures were not followed. The DON acknowledged that medications should not be left at bedside unless a self-administration assessment was completed and appropriate storage, such as a lock box, was provided.