Failure to Secure Medications at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with state and federal requirements, specifically by allowing a medication to be left at the bedside of a resident. Facility policy requires that medications stored at the bedside be kept locked in a secure container, and that nurses are responsible for maintaining medication storage in a clean, safe, and sanitary manner. However, multiple observations revealed that an albuterol inhaler was left on the over-bed table of a resident with moderate cognitive impairment and a history of asthma, anxiety, and malnutrition. The inhaler was observed unattended on several occasions, including when the resident was not present in the room and the door was open. Review of the resident's records showed no physician's order for self-administration of medications, no care plan for self-administration, and no assessment indicating the resident was capable or desired to self-administer medications. In fact, documentation indicated the resident did not want to self-administer medications. During interviews, both the nurse and the resident confirmed that the inhaler had been left at the bedside by staff, contrary to facility policy and regulatory requirements.