F0755

D

Medications Left at Bedside Without Ensuring Administration

El Cajon, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure complete and safe medication administration for a resident when ordered medications were left at the bedside and not verified as taken. The resident, who had diagnoses including congestive heart failure and anxiety disorder and physician orders for morning doses of Furosemide 40 mg and Lorazepam 0.5 mg, was observed lying in bed with eyes closed while two white, round pills remained in a medication cup on the bedside table. A nurse confirmed the presence of the pills and identified that another licensed nurse was the assigned medication nurse for the resident. Review of the Medication Administration Record and the medication cart, along with the photograph of the pills, established that the pills were the resident’s scheduled morning doses of Lorazepam and Furosemide.

The assigned nurse stated she had administered the medications at 9:34 a.m. but acknowledged that she left the Lorazepam and Furosemide at the resident’s bedside when she went to assist the resident’s roommate and did not ensure the resident actually took the medications. Facility staff, including another licensed nurse, the director of staff development, and the DON, all stated that complete medication administration requires ensuring residents safely and fully swallow medications, including checking the mouth, and that medications should not be left at the bedside or on a bedside table. Facility documents, including a lesson plan on nursing documentation and the policy on administering medications, indicated that residents must take and swallow medications before staff leave the room and that no medications should be left by the bedside, and that medications are to be administered in a safe and timely manner as prescribed.