Medications Left Unattended at Bedside and Not Administered as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescribed medications were properly administered and not left unattended at a resident’s bedside. A cognitively intact resident with diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia had multiple medications ordered: Velphoro 500 mg three times daily for hypokalemia at 7:00 AM, 11:00 AM, and 4:00 PM; sucralfate 1 gram four times daily, to be given 30 minutes before meals and at bedtime; and midodrine 10 mg once daily and 5 mg twice daily, to be held if systolic blood pressure exceeded 130 mmHg. During observation, four plastic medication cups containing a large round brown tablet (Velphoro), a white oblong tablet (sucralfate), and a small white pill (midodrine) were found on the resident’s bedside table while the Medication Aide assigned to the cart was outside the room and could not see the resident. The Medication Aide confirmed the medications belonged to the resident and stated they must have been left from a prior shift’s medication pass, acknowledging she had not yet administered that morning’s medications and had not been in the room. She reported being assigned to the resident on the prior day’s 7:00 AM–3:00 PM shift but did not recall leaving medications at the bedside, and stated that medications should never be left at the bedside and residents should be observed swallowing them. A nurse assigned to the resident on the 3:00 PM–11:00 PM shift the same day also did not recall leaving medications at the bedside but agreed it was not appropriate to leave medications unattended and unsecured. The resident reported that nurses often left medications at the bedside for self-administration and did not always inform him that the medications were there or that he was expected to take them. The physician stated that the resident not receiving Velphoro, sucralfate, and midodrine as prescribed had the potential to result in significant adverse effects, and the Unit Manager and DON both stated that medications were not to be left at the bedside and that staff were expected to remain with residents to observe medication ingestion unless the resident had been assessed and approved for self-administration, which had not occurred in this case.
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