Failure to Secure Medications and Treatment Solutions
Penalty
Summary
The facility failed to ensure that all medications and wound treatment solutions were secured and not left unattended in public hallways or resident rooms for five residents. Surveyors observed multiple instances where medication cups containing unidentified pills, inhalers, and creams were left on over-bed tables, breakfast trays, or handrails, accessible to residents without proper supervision. In each case, there was no documentation of an assessment for self-administration of medications, no physician's order permitting self-administration or medications at bedside, and no care plan addressing self-administration. For example, one resident was found with a cup of unidentified pills on the bedside table, and another had a medication cup and inhaler left on a breakfast tray while sleeping in a wheelchair. Additional observations included residents with various medications, eye drops, inhalers, and supplements among their personal items, some of which lacked pharmacy labels, had unreadable labels, or no visible expiration dates. In one case, a medication cup with white cream was left on a handrail outside a resident's room. Record reviews confirmed that the medications had been documented as administered by nursing staff, but there was no evidence of proper authorization or assessment for residents to keep medications at bedside. Interviews with facility staff, including the administrator and regional nurse consultant, confirmed that staff were aware that prescription medications should not be left at bedside without an order. Facility policies provided by the regional nurse consultant required medications to be administered by licensed staff and stored securely, accessible only to authorized personnel.