Failure to Prevent Accident Hazards Due to Unsecured Medications at Bedside
Penalty
Summary
Facility staff failed to ensure a resident's environment was free from accident hazards when over-the-counter medications, specifically a bottle of Zyrtec and a nasal spray, were found on a resident's bedside table. The medications were brought in by the resident's son and remained accessible for approximately 21 hours across three shifts before being removed by staff. During this period, other residents could have accessed the medications. The resident, who was cognitively intact with a BIMS score of 15/15, acknowledged receiving the medications from her son and stated she was aware she was not supposed to have them. Record review revealed there were no physician orders for the nasal spray, no orders permitting self-administration of medications, and no assessment for self-administration documented in the resident's record. The resident's care plan did not address self-administration of medications. Interviews with LPNs confirmed that the facility's process requires physician approval, a nursing assessment, and care plan updates before a resident may self-administer medications, none of which were completed in this case. Staff also indicated that both the resident and her son had previously been educated not to bring medications into the facility.