Unsecured Medications Left at Bedside for Non-Authorized Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with costochondritis and assessed as cognitively intact, was found to have medications stored unsecured at the bedside. The resident had not been approved for self-administration of medications, as documented in the assessment, and physician orders required staff to administer Diclofenac Sodium gel. Despite this, observations revealed a tube of Hydrocortisone cream and a medication cup containing a whitish gel-like substance left in the resident's room. The resident reported using both the Hydrocortisone cream, which was brought by family, and the unidentified gel, which she applied daily for pain but could not name. Staff interviews confirmed that medications should not have been left in the resident's room, as she was not authorized for self-administration. The DON was unable to identify the substance in the medication cup but stated it should not have been present, and nurses on duty denied leaving or noticing the medications at the bedside. The administrator confirmed the expectation that medications be stored appropriately, but the medications remained accessible to the resident in violation of facility policy and professional standards.