Medications Left Unattended at Bedside Without Ensuring Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with professional standards and the facility’s own medication administration policy. The policy required that medications be administered at the time they are prepared, by the same person who prepares them, and that residents be observed after administration to ensure the dose is completely ingested. During an interview and observation on 3/5/26 at 9:12 a.m., a medication cup containing seven pills and a separate large pink pill were observed on Resident #12’s bedside table, with no nurse present in the room. Resident #12 stated that the medications had been given to her, that she was supposed to take them, and that the nurse had handed them to her and then walked out. At 9:20 a.m., RN Staff A was observed at the medication cart and confirmed she had administered medications to Resident #12. When informed about the unattended pills, RN Staff A initially stated she had watched the resident take the whole cup and swallow the medications. At approximately 9:23 a.m., when RN Staff A and the surveyor returned to Resident #12’s room, the medication cup with the seven pills and the pink pill were still on the bedside table. RN Staff A questioned the resident about not taking the medications and then acknowledged she had given the medications and left the room without ensuring they were ingested, stating she knew this was wrong. These observations and interviews demonstrate that the nurse did not follow the facility’s policy or accepted professional standards for medication administration.
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