The friend found the pills during a visit and immediately alerted nursing staff. The medications were later identified as Protonix, used to treat excess stomach acid, and Labetalol HCl, a blood pressure medication that the resident takes each morning.
LVN B, an agency nurse working the 2:00 pm to 10:00 pm shift that day, responded when the friend called her from the nurse's station. The nurse followed the friend back to the room where two pills lay on the tray table.
"She picked up the two pills and took them to the nurse's station to investigate," according to the inspection report. After checking the computer system, LVN B returned to inform the friend what medications had been found.
The nurse told the friend she would not give the resident additional doses because the morning medications already showed as administered in the electronic records. She checked the resident's blood pressure, which was normal, and said she would provide the evening medications as scheduled.
LVN B stated she reported the incident to either the Director of Nursing or Assistant Director of Nursing by phone and was instructed to document it in the facility's 24-hour log report.
But no such documentation exists.
Inspectors found no record of the incident in the facility's 24-hour report book, despite the nurse's claim that she had documented it there.
The Director of Nursing told inspectors she learned about the incident when the resident's friend told one of her nurses about finding pills on the floor. She started an investigation to determine how the medications ended up there, theorizing that "maybe the nurse tried to throw the pills in the trash."
The DON said her staff was unaware of any medication being on the floor until the resident's friend brought it to their attention.
The Assistant Director of Nursing confirmed that the resident's friend had told a nurse about finding medication at the bedside. She said she instructed the nurse to document the incident and assess the resident.
The friend expressed concern about not knowing how long the pills had been on the floor. The medications were identified as part of the resident's regular morning routine, but the timeline of when they were dropped or how they ended up scattered in the room remains unclear.
Agency nurses like LVN B work temporary shifts at facilities and may be less familiar with individual residents' routines and medication schedules than permanent staff. The nurse had only started her shift shortly before being called to investigate the pills.
Bear Creek's own policy on unused drugs, implemented and revised during the inspection period, requires that "all unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations." The policy references state-specific requirements for proper medication disposal.
The incident raises questions about medication handling procedures and whether pills regularly end up on floors without staff knowledge. Blood pressure medications like Labetalol HCl require careful monitoring, as missing doses can affect a resident's cardiovascular health.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the discovery of prescription medications on the floor, combined with the lack of required documentation, suggests gaps in the facility's medication safety protocols.
The resident's friend, who was not identified in the inspection report, played a crucial role in alerting staff to the medication safety issue. Without the visitor's vigilance, the pills might have remained on the floor indefinitely.
LVN B administered the resident's evening medications as planned after determining the morning doses had already been given. The resident's blood pressure reading was stable when checked following the incident.
The investigation by facility leadership focused on how the pills ended up on the floor, but inspectors found no evidence that staff had identified or addressed the underlying cause of the medication handling failure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bear Creek Nursing and Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
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