Failure to Prevent Accident Hazards: Unsecured Medications and Razors
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident was observed with multiple medications, including narcotics and other prescription drugs, left unattended at the bedside on two separate occasions. The resident reported retrieving medications from the medication cart due to perceived delays and keeping some pills to take later or not at all. There was no physician order or care plan in place permitting self-administration of medications, nor was there an assessment for the resident's ability to self-administer. Facility staff interviews confirmed that medications should not be stored at the bedside without proper orders and care planning, and that nurses are responsible for ensuring medications are taken as prescribed and not left with the resident unless authorized. In the second instance, another resident with severe cognitive impairment and on anticoagulant therapy was found with several razors stored in a plastic bag on the dresser in their room. The resident required significant assistance with activities of daily living and had a history of impaired cognitive function. Staff interviews revealed that razors are typically stored in locked supply closets and are only provided to residents deemed safe to use them, with supervision recommended. There was no policy provided regarding the safe handling or storage of razors in resident rooms during the survey. A review of facility policies indicated requirements for medication administration and general safety precautions, but there was a lack of specific guidance or implementation regarding the safe storage of medications and razors in resident rooms. The facility's failure to follow its own procedures and ensure proper assessment and authorization for self-administration of medications, as well as the improper storage of potentially hazardous items like razors, contributed to an environment that was not as free from accident hazards as possible for the affected residents.