Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered medications were properly administered to a resident and not left unattended. The resident had intact cognition with a BIMS score of 15 and diagnoses including unspecified vitamin deficiency, anemia, and vitamin D deficiency. Physician orders in the EMR included daily ferrous sulfate for anemia, a daily multivitamin for vitamin supplementation, and daily cholecalciferol for vitamin D. The resident’s care plan indicated a need for some assistance with ADLs due to arthritis and physical challenges. During a morning medication pass, the resident was found awake in bed wearing a hospital gown with three pills (a small white tablet, a medium off-white tablet, and a medium black tablet) on her chest. The resident stated she had been given her medications in a cup but must have missed her mouth. When questioned, an LPN confirmed she had given the medications to the resident in a medicine cup but did not notice that the resident had not taken them, and identified the pills as a multivitamin, iron, and a medication “to reduce fat.” The LPN was in the hallway when the pills were discovered rather than remaining with the resident. The Unit Manager (an RN) stated there were no residents who self-administered medications and confirmed that the LPN should have stayed with the resident to ensure the medications were taken, adding that medications should never be left with the resident. The DON also stated there were no residents who self-administered medications and that her expectation was for the nurse to stay with the resident until medications were taken, and she was unaware of the incident at the time it occurred. The facility’s Medication Administration policy stated that medications should never be left at the bedside to be taken later, but did not specifically include language requiring staff to ensure residents actually take the medications.
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