Failure to Secure Medications and Ensure Functionality of Bed Pad Alarms
Penalty
Summary
A deficiency was identified when a resident was found to have multiple bottles of supplements and medications stored at their bedside, accessible to other residents. The resident's care plan noted that the family requested supplements be kept at the bedside, but the resident's assessment indicated they were not safe to self-administer medications and required staff assistance for all medication administration. Despite this, the medications were left in a plastic bag at the bedside, and both the Director of Social Service and the DON confirmed the presence of these medications. Facility policy required that medications be stored securely and only accessible to authorized personnel, which was not followed in this instance. Additionally, the facility failed to ensure daily checks and documentation of the functionality of bed pad alarms for two residents identified as high fall risks. Both residents had severe cognitive impairment and required substantial assistance with daily activities. Observations confirmed that both residents were using bed pad alarms, but staff were unable to demonstrate or document that the alarms were checked for proper functioning as required by facility policy. Interviews with nursing staff and the DON revealed a lack of clarity on where or how the checks were to be documented, and in one case, a nurse stated the alarm was not functioning. The facility's policies required that personal alarms be checked daily for proper functioning and that nursing staff monitor and document their status. However, record reviews for both residents did not show any evidence that these checks were performed or documented. This lack of adherence to policy and procedure resulted in a failure to provide an environment free from accident hazards and adequate supervision to prevent accidents for the residents involved.