Failure to Secure Self-Administered Medications in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used by residents with physician orders for self-administration were stored in locked compartments, as required by regulation. Four residents with intact cognition and various medical conditions, including neuralgia, neuropathy, asthma, glaucoma, and chronic pain, were observed storing their self-administered medications in unsecured locations within their rooms. Specifically, medications were found in unlocked dresser drawers, unlocked nightstand drawers, and on top of bedside tables and nightstands, making them accessible to others. Interviews with the residents confirmed that these unsecured storage methods were their usual practice. The Director of Nursing (DON) acknowledged that four residents had physician orders to self-administer medications and stated that staff believed medications were safely stored by keeping them out of reach. However, the DON also indicated that residents were instructed not to keep medications in visible or easily accessible places, which was inconsistent with the observed practices. A review of the facility's policy on self-administration of medications revealed that it did not address the storage of medications in residents' rooms. The lack of secure storage for self-administered medications was identified through direct observation, resident interviews, and record review, demonstrating a failure to prevent unintended access to medications by other residents.