Medications Left Unattended in Resident Room During Administration
Penalty
Summary
A medication aide (MA) failed to provide proper supervision during medication administration for a resident with multiple complex medical conditions, including hypertension, diabetes mellitus, and Alzheimer's disease. The resident was cognitively intact, as indicated by a BIMS score of 13, and had not been assessed for self-administration of medications. During morning medication administration, the MA left a cup containing nine prescribed medications and supplements on the resident's bedside table while she was eating breakfast, without supervising her to ensure the medications were taken as ordered. The resident later confirmed that staff typically observed her taking medications, but on this occasion, the MA left the medications in her room because he was busy. The MA admitted to leaving medications in resident rooms when residents refused or were occupied, and acknowledged that he was not supposed to do so. The facility's policy required staff to observe residents taking medications unless a formal assessment for self-administration had been completed and approved by the care planning team and physician. Interviews with multiple facility staff, including assistant directors of nursing and the director of nursing, confirmed that leaving medications unattended in resident rooms was against facility policy and posed risks, such as residents not taking their medications or other residents accessing them. At the time of the incident, no residents had been approved for self-administration of medications, and there was no documentation supporting such an assessment for the resident involved.