Unattended Nicotine Lozenge Left at Bedside Without Self-Administration Authorization
Penalty
Summary
Nursing staff failed to ensure medications were properly administered and not left unattended at the bedside for a resident with an order for nicotine lozenges. The resident had a diagnosis of nicotine dependence and a physician’s order for nicotine 2 mg lozenges to be given as needed. During observation, the resident was found lying in bed with a clear plastic medication cup containing a single white circular tablet on the bedside drawer, with no nursing staff present. The resident stated the tablet was a nicotine wafer that the nurse had left there and then ingested the tablet, stating he hoped it was the nicotine lozenge. Further review showed that the MAR documented administration of one 2 mg nicotine lozenge earlier that morning, while the RN reported having given two lozenges and only witnessing the resident take one. The RN stated that because the lozenges were ordered as needed, she did not believe she had to see the resident take them. The supervising RN confirmed that medications should not be left unattended at the bedside and that the resident had not been evaluated for self-administration of medications. Another RN confirmed there was no physician order for the resident to self-administer medications. The facility’s medication administration policy required that medications be promptly given to the proper resident as part of the complete act of administration.
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