Unsecured Medications Left Unattended on Med Cart and at Bedside
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely and not left unattended on medication carts or at residents' bedsides. Surveyors observed a bag of Vancomycin 1 g/200 mL left on top of an unattended medication cart on the 400 hall while the assigned RN was in a resident room on a different hall. The RN later acknowledged the medication should not have been left on top of the cart. The DON stated that medications should not be left unattended on carts, and facility policy on medication storage requires that during a medication pass, medications must be under direct observation of the person administering them or locked in the medication storage area or cart. The deficiency also includes medications left unattended in a resident’s room. A resident was observed with medication at the bedside, and an RN entered the room and immediately went to the medications to administer the remaining dose. The resident reported the medication had been at the bedside for at least 30 minutes and stated staff always leave medications at the bedside so they can take them later. The RN did not comment and removed the empty medication cup after administration. Record review showed this resident was cognitively intact with a BIMS score of 15 and had diagnoses including a left femur neck fracture with routine healing, left hip pain, hypertensive urgency, anxiety disorder, and recurrent moderate major depressive disorder. The resident was receiving multiple medications including antidepressants, antianxiety agents, anticoagulants, opioids, antiplatelet agents, levothyroxine, lisinopril, and pravastatin. There was no documentation in progress notes or the care plan indicating the resident requested to take medications later, no physician or family advisement, and no care plan addressing a tendency to delay or hold medications, despite staff interviews and facility policy stating that medications should not be left unattended with residents.
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