Unattended Medications Left in Cognitively Impaired Resident’s Room
Penalty
Summary
The deficiency involves the facility’s failure to prevent medications from being left unattended in a resident’s room, contrary to facility policy requiring that medications not be left unattended and that staff observe residents consuming medications. Resident #19, admitted on 05/25/25 with diagnoses including dementia, mild cognitive impairment, and hallucinations, had an MDS assessment indicating impaired cognition. On 01/14/26 at 12:38 P.M., surveyors observed two separate medication cups in the resident’s room: one on a dresser under the television containing three white pills, and another on the nightstand next to the bed containing eight medications. During the observation, Resident #19 stated she was unaware of when the medications had been delivered and reported that staff sometimes brought medications while she was sleeping, leaving her unaware they were present. At 12:42 P.M., LPN #234 reported having administered the resident’s morning medications between 8:00 A.M. and 9:00 A.M. and stated she had observed the resident consume them. Upon observing the two medication cups, LPN #234 confirmed that the cup with eight pills contained the resident’s morning medications and acknowledged she did not know what the three white pills were, as she had not administered them. LPN #234 acknowledged that medications should not be left unattended in resident rooms. This failure to ensure medications were not left unattended affected one resident out of four observed for unattended medications during the complaint investigation.
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