Failure to Secure Medications and Lock Medication Carts
Penalty
Summary
The facility failed to ensure that medications were securely stored and not left unattended at residents' bedsides or in unlocked medication carts. Facility policy required that medication carts be locked when not in use and that medications should not be stored in residents' rooms unless approved for self-administration by the physician and care planning team. Observations revealed that topical medications, including antifungal powder and wound dressing cream, were found at the bedsides of multiple residents without proper authorization or documentation. Additionally, a medication treatment cart was observed unlocked in a hallway accessible to residents, containing various topical medications and supplies. Interviews with staff, including LPNs and the DON, confirmed that medications should not be left at the bedside or in unlocked carts, as this could allow residents, including those with cognitive impairments or wandering behaviors, to access and potentially misuse the medications. Staff were unaware that certain medications were left at the bedside, and there was no evidence that any residents had been assessed or approved for self-administration of medications. The DON also stated that the facility did not have a self-administration policy in place and that no residents had been granted self-administration rights. Medical record reviews for the involved residents showed that some had significant medical conditions, such as schizophrenia, kidney disease, osteomyelitis, and multiple skin integrity issues, requiring careful management of their medications and treatments. Despite these needs, medications were not consistently documented on treatment records, and some medications found at the bedside were not ordered by the physician. The facility's failure to follow its own policies and ensure secure medication storage resulted in the potential for residents to access and use medications inappropriately.