Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as prescribed and not left unattended, resulting in one resident not receiving ordered medications. The resident had diagnoses including essential primary HTN, unspecified a-fib, and anemia, and required supervision with toilet hygiene and showering/bathing, but was independent with eating and oral hygiene. The resident’s MAR for a specific date in February 2026 showed that multiple medications, including chlorthalidone, ferrous sulfate, memantine HCL, a multivitamin, docusate sodium, and hydrochlorothiazide, were documented as administered at 9:00 a.m. However, observation later that morning showed that a medication cup containing six pills remained on the resident’s bedside table at 10:00 a.m. and again at 11:29 a.m., indicating the medications had not been ingested. An LVN reported that she had placed the medication cup with pills on the bedside table and left the room because she was called to assist another resident, acknowledging that this was not her usual practice and that medications should not be left unattended. The DON confirmed that licensed nurses were not to leave medications unattended at the bedside. The facility’s medication administration policy stated that if a resident is unavailable to receive medications, the MAR should be flagged and the nurse should return after the medication pass to administer the dose and observe the resident to ensure it is completely ingested.
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