Unattended Oral Medications Left at Bedside Contrary to Facility Policy
Penalty
Summary
Facility staff failed to ensure medications were administered as ordered and properly stored until administration for one resident. The resident had paraplegia, was ventilator dependent, and had a stage four pressure ulcer, with an admission date of 05/14/25. A quarterly MDS indicated the resident had intact cognitive function and required set up for eating, and the care plan documented a need for assistance with activities of daily living due to weakness, with an intervention to administer medications as ordered. Physician orders included Xarelto 10 mg by mouth in the morning, Ferrous Sulfate 325 mg by mouth once daily, and Fludrocortisone Acetate 0.1 mg, two tablets by mouth daily for blood pressure. On 03/17/26 at 8:13 A.M., surveyors observed a small medication cup containing four medications left on the resident’s bedside table while the resident was in bed sleeping with a sheet over his head, and the nurse was down the hall at the nurse’s station. The unit manager confirmed that the medications in the cup were Xarelto, Ferrous Sulfate, and Fludrocortisone Acetate and verified that the medications had been left unattended in the room while the resident was sleeping. Review of the facility’s “Administering Medications” policy, revised April 2019, showed that medications were to be administered in a safe and timely manner as prescribed, with medication administration times determined by resident need and benefit, and that during administration medications were to be kept in the sight of the nurse until given to the resident. The observed practice of leaving medications unattended in the resident’s room was inconsistent with this policy.
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