Improper Storage and Unauthorized Access to Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not stored in accordance with professional standards and facility policy. In one case, a resident had a bottle of spray at their bedside, which the resident reported using at night. Staff confirmed that residents are not permitted to self-administer medications without an evaluation, care plan, and physician order, none of which were in place for this resident. Another resident had a bottle of lubricant and powder on their bedside table and air conditioning unit, stating that they used these items as needed, sometimes with nurse assistance. A third resident had a tube of an unidentified substance at their bedside, which staff confirmed was not ordered and was brought in by family without staff knowledge or approval. In each case, staff acknowledged that the residents were not authorized to self-administer medications and that such items should not be accessible without proper assessment and documentation. Additionally, a medication cup containing a white pill was found unattended in a resident's room. The resident was unaware of the medication's purpose, and the LPN stated they believed the resident had already taken all medications. The DON confirmed that no residents in the facility were authorized to self-administer medications and that medications should not be left unattended in resident rooms. Facility policies reviewed by surveyors required that medications be stored securely and that self-administration only occur following interdisciplinary assessment and physician order, which was not followed in these instances.