Failure to Secure and Store Medications Properly
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly secured and stored in accordance with professional standards for two residents. For one resident with a diagnosis of Type 2 Diabetes Mellitus and a BIMS score indicating intact cognition, a tube of prescription Mupirocin ointment 2% was observed on the dresser in plain sight on two separate occasions. There was no physician's order for this medication, nor an order permitting self-administration. Staff confirmed that medications should not be kept at the bedside unless the resident has been assessed and approved for self-administration, which was not the case for this resident. In another instance, a different resident with similar diagnoses and cognitive status was found to have four large bottles of over-the-counter supplements, including Calcimate Plus with Magnesium and Vitamin D-3, Magnesium Citrate, Probiotic gummies, and High-Metabolite Immunogens, unsecured and accessible on the bedside table. The resident reported that her daughter brought the supplements, but she had not taken them and was unaware of any physician's order for their use. Record review confirmed there were no orders for these supplements or for self-administration, and the care plan did not address self-administration. Staff interviews indicated that medications at the bedside should be confiscated and held for family pickup, and the assigned nurse was unaware of the presence of these supplements.