Unsecured Bedside Medications and Unauthorized Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and not left unattended at residents’ bedsides. On 2/23/2026 at approximately 10:00 a.m., during a facility tour, medications were observed on bedside tables in the rooms of ten residents, with no staff present in any of the rooms at the time. In one room, a resident was seated while a medication cup containing oral medications was on the bedside table. During this observation, another resident picked up the medication cup and independently ingested the medications without any licensed nurse or staff member present. On 2/24/2026 at approximately 7:30 a.m., medications were again observed on bedside tables in multiple residents’ rooms with no staff present. Record review later that day showed there were no physician orders authorizing self-administration of medications and no documented assessments of the residents’ ability to safely self-administer medications for any of the residents whose rooms contained unattended medications. An RN observed administering medications on 2/24/2026 at approximately 8:00 a.m. followed standard medication administration practices and stated that medications were not to be left at the bedside and that residents must be observed swallowing medications in the nurse’s presence, but she could not explain how the medications came to be left in the residents’ rooms.
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