Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
Surveyors identified that a registered nurse failed to secure a medication cart when leaving it unattended to check a resident's blood sugar. The nurse admitted to forgetting to lock the cart and acknowledged responsibility for ensuring it was secured. Facility leadership, including the Regional Compliance Nurse and Administrator, confirmed that medication carts are expected to be locked when unattended to prevent unauthorized access. Additionally, a resident with COPD and asthma was observed multiple times with a labeled Albuterol inhaler on her dresser, which she reported using as needed and stated she brought from home. The medication was also found on the nurse's medication cart at one point, and the resident indicated she had informed someone at the facility about possessing the inhaler, though staff were unaware. The resident had not been assessed for self-administration of medication, and the inhaler was not secured as required by facility policy. Another resident was found with a tube of nystatin cream on her bedside table, which she stated was brought by her husband and used for itching. There was no physician order for the cream, and the resident had not been assessed for self-administration. Staff later instructed the resident to have the medication removed, but were initially unaware of its presence. Facility policy requires medications to be stored securely and only accessible to authorized personnel, and mandates assessment and physician order for self-administration, which was not completed in these cases.