Medications Improperly Stored and Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and not kept at the bedside, as required by facility policy and professional standards. In one instance, a bubble pack of metformin prescribed for a resident with diabetes was found hidden in another resident's closet for ten days. The investigation revealed that a CNA, who also had diabetes, took the medication from the medication room when the door was left slightly open and hid it in the resident's room with the intention of taking it home, but forgot about it until it was discovered by the resident's family. The resident whose closet was used to hide the medication had no capacity to understand or make decisions, as documented in their medical record. Additionally, another resident's side table drawer was found to contain a medication cup filled with thick white cream and a tongue depressor, which the DON identified as zinc oxide cream prescribed for a pressure injury. This medication was not stored securely as required. Both incidents were acknowledged by facility leadership and were in direct violation of the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and not stored at the bedside.