Unattended Bedside Medications Left by Medication Aide
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administering of medications when a medication aide left a resident’s medications unattended at the bedside. The resident was an older male with COPD, chronic respiratory failure with hypercapnia, muscle weakness, heart failure, hypertension, impaired visual function, ADL self-care deficits, and moderate cognitive impairment (BIMS score of 7). His care plan reflected he required assistance with feeding, was on a mechanical soft diet with thin liquids, and used antidepressant/anxiety medications. There was no assessment documented for self-administration of medications or competency to manage his own medications. On the morning in question, the resident had multiple scheduled medications, including antihypertensives with hold parameters, GI medications, constipation medication, vitamin C, and ferrous sulfate. The MAR for that day showed he received vitamin C, famotidine, protonix, ferrous sulfate, and sennosides-docusate sodium, and that all blood pressure medications were held due to vital signs being out of range. During the morning med pass, the medication aide crushed the ordered medications, mixed them with pudding, and placed the medication cup on the resident’s bedside table, informing him that his medications were there and then leaving the room without remaining to observe administration. Subsequent observation showed the medication cup remained on the bedside table after the aide left, and the resident stated he was going to take the medications. Later, the cup was no longer present, and the resident reported that staff left medications on the table when he was busy and that he took them himself; he confirmed staff did not watch him take his medications that day. The medication aide acknowledged leaving the medications in front of the resident at his request, admitted she did not see him take them, and stated she knew she was not supposed to leave medications in the room. Facility leadership, including the ADONs, DON, and Administrator, each stated that staff were expected to follow the medication administration policy, complete the rights of medication administration, remain with residents until medications were swallowed, and never leave medications unattended, and they identified that no residents in the facility were authorized to self-administer medications. The facility’s written Medication Administration: Medication Pass policy required staff to remain with the patient until administration of medications was complete and to document each medication administered on the MAR.
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