Failure to Secure and Monitor Resident Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals for two residents who had medicated creams and over-the-counter treatments at their bedsides. One resident with dementia, gout, and peripheral vascular disease was observed with a lidded pump container of prescription topical medicated cream for foot pain on his bedside table. The resident stated he brought the cream from home and applied it as needed, but there was no physician order for the medication, and staff were unaware of its presence. The resident was not assessed as able to self-administer medications, and the cream had an expired date. Multiple staff members, including a medication aide and a nurse, reported not noticing the cream in the resident's room during their medication administration duties. Another resident, who was cognitively intact but required extensive assistance with activities of daily living, was found with several over-the-counter medicated products on her bedside tray, including rubbing alcohol, medicated gels, cortisone cream, vapor rub, and oral pain relief gel. The resident reported using these products for various ailments and stated she obtained them from family and friends. There was no documentation of a physician order or an assessment for self-administration of medications or treatments in her medical record. Staff members, including nurses and medication aides, were unaware that the resident possessed or self-administered these products and had not paid close attention to the items on her bedside tray. Interviews with the Medical Director, Director of Nursing, and Administrator confirmed that residents should not have medications or treatments in their possession or self-administer without a physician order and proper assessment. The staff's lack of awareness and failure to observe and remove unauthorized medications from residents' rooms contributed to the deficiency in ensuring drugs and biologicals were properly labeled and securely stored according to professional standards.