Failure to Secure Medications and Prevent Resident-to-Resident Intrusions
Penalty
Summary
The facility failed to store medications and treatment supplies in a secure environment, as observed with a bottle of Dakins solution and a tube of Therahoney left unattended in a resident's room. According to facility policy, such items should be locked away when not in use to prevent access by unauthorized individuals. Staff confirmed that these items should not have been left in the room, especially given the presence of multiple residents with wandering behaviors who could potentially access them. Additionally, the facility did not adequately address the issue of confused residents entering another resident's room. Two residents with documented cognitive impairments and high risk for wandering were observed entering the room of another resident on multiple occasions. The resident whose room was entered reported frequent disturbances, including one incident where a confused resident fell onto her, resulting in soreness and bruising. Despite these repeated intrusions, staff did not implement effective measures to prevent such occurrences. Furthermore, the facility failed to investigate and document follow-up care after the incident in which a confused resident fell onto another resident, causing physical discomfort. There was no evidence in the medical record of any assessment or follow-up regarding the injury, and the administrator was unable to provide information on steps taken to prevent further incidents or to investigate the reported injury. This lack of action left the affected resident without appropriate support or intervention following the event.