Unattended Medications Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to medication storage and administration when a resident’s crushed medications mixed in a tea-colored liquid were observed in a clear plastic cup left unattended on the bedside table. During an unannounced complaint visit, the resident was observed lying in bed with eyes closed while the medication cup remained at the bedside. The resident’s admission record showed diagnoses including attention to gastrostomy and seizures, and the MDS assessment had a blank BIMS cognition section. Physician orders indicated the resident was to receive ascorbic acid 500 mg, furosemide 40 mg with parameters to hold for systolic blood pressure less than 100, and a multivitamin with minerals, all to be administered via G-tube in the morning. The MAR for the same date showed these medications as administered and signed off by a licensed nurse. In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water and acknowledged she should not have left them in a clear cup at the bedside because some residents or someone might pick them up and swallow them. The DON stated that medications should not be left anywhere in resident rooms unattended and emphasized this was important for resident safety. Review of the facility’s “Storage of Medications” policy stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, that compartments containing biologicals shall be locked when not in use, and that items shall not be left unattended. The observed practice of leaving medications unattended at the bedside was inconsistent with this policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.