Unsecured Medications Left at Bedside Contrary to Facility Policy
Penalty
Summary
Surveyors identified a deficiency in medication storage and administration when a resident’s morning medications were found unsecured on her bedside table. The resident, a female with delusional disorder and schizophrenia, had an intact BIMS score of 14 and was independent in functional abilities. Her care plan contained no evidence that she was permitted to self-administer medications or keep medications in her room. Record review of her Medication Administration Record showed that four different medications (six tablets) were documented as given that morning, although exact administration times were not listed. At 10:02 AM, surveyors observed a small medication cup with medications at the resident’s bedside; the resident stated the medications had not been there long, that she needed to take them, and then immediately took them herself, explaining she must have been asleep and staff were not able to wake her. Interviews with nursing staff and the DON confirmed that the facility’s established process required nurses or medication aides to verify the MAR, identify the correct resident, and remain with the resident to observe consumption of medications, and that medications were never to be left in a resident’s room. RN and LVN staff both stated they would not leave medications with residents and described this as a clear rule. The facility’s written Medication Administration policy required observation of resident consumption of medication, and the Medication Storage policy required all drugs and biologicals to be stored in locked compartments, with medications under the direct observation of the person administering them or locked in the storage area/cart during a medication pass. Despite these policies and staff statements, the resident’s medications were left unattended at the bedside, unsecured and not under direct observation, constituting a failure to follow facility policy and regulatory requirements for medication storage and administration.
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