Unsecured Potassium Capsule Left at Bedside Without Self-Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to properly secure and store a prescribed medication, specifically a potassium citrate capsule, for a resident who did not have an order or care plan to self-administer medications. The resident, cognitively intact and admitted with acute systolic heart failure and hypokalemia, had a physician’s order for a daily 20 mEq potassium citrate capsule. Surveyors observed a large white pill in a medication cup left on the bedside table while the resident was in bed. Review of the EMR confirmed there were no orders or assessments authorizing self-administration of medications for this resident. During interviews, the nurse assigned to administer medications that morning acknowledged she had given the resident her medications and confirmed the pill at the bedside was the potassium citrate capsule. She stated the resident preferred to take that pill later and admitted she left it at the bedside after being called away by another staff member, instead of returning it to the medication cart. The resident confirmed she did not like to take the large white pill with her other medications and that the nurse did not remove it. The NP stated the resident had never had an order to self-medicate and would not be able to self-medicate, and that medications should never be left at the bedside. The DON and Administrator both indicated the resident had no self-medication order and that the nurse should have removed the pill rather than leaving it at the bedside.
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.