Medications Improperly Stored in Resident Room Without Authorization
Penalty
Summary
Surveyors found that the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards and manufacturer specifications for one resident. Multiple medications and wound care supplies, including deep sea nasal spray, nystatin topical powder, latanoprost eye drops, refresh tears, and Preparation H cream, were observed in the resident's room on the bedside table, nightstand, and windowsill. There was no documented evidence of a physician's order allowing the resident to self-administer these medications, nor was there a care plan in place for self-administration. The resident, who had diagnoses including glaucoma, blepharitis, and foot drop, was assessed as having intact cognition. The resident reported self-administering several of the medications, stating that nurses had left them in the room or that they had received some as gifts. The resident also indicated that they preferred to apply certain treatments themselves, such as the nystatin powder and eye drops, and used the nasal spray independently. However, staff interviews confirmed that there were no orders or care plans authorizing self-administration, and that medications should not be left in resident rooms unless such authorization exists. Nursing staff, including an LPN, RN Unit Manager, and the Medical Director, all stated that medications are not to be kept in resident rooms without proper orders and care planning. The Medical Director confirmed that no order had been written for self-administration, and the interim DON reiterated that medications should not be left in resident rooms. The presence of these medications and supplies in the resident's room, without appropriate documentation or authorization, constituted a failure to comply with medication storage regulations.