Medications Improperly Left at Bedside Without Authorization or Proper Storage
Penalty
Summary
Multiple residents were found with medications at their bedside that were not properly stored or authorized for self-administration. One resident, with a history of chronic systolic congestive heart failure and other conditions, was observed with unopened Estradiol Vaginal Cream and Betamethasone Dipropionate Ointment on her table. These medications were brought in by the resident's family without notifying facility staff, and there were no physician orders or care plan documentation permitting self-administration. Staff interviews confirmed that such medications should not be left at the bedside and that they were unaware the resident had them. Another resident, diagnosed with metabolic encephalopathy and other conditions, was found with CryoDose Topical Anesthetic Spray and Zinc Oxide Cream on his table. These items were brought in by the resident's wife, who claimed one of the medications as her own and removed it from staff when approached. There were no physician orders or care plan documentation for self-administration for this resident either. Staff interviews indicated that these medications should not be accessible at the bedside due to potential risks, and the facility's policy requires immediate removal and physician notification if such medications are found. A third resident, with a history of concussion, diabetes, and other conditions, was observed with a pill (believed to be Tylenol) left on her personal cell phone. The resident stated that pills are often left in a medicine cup at her bedside. Staff confirmed that medications should not be left at the bedside and that this practice was not in accordance with facility policy. In all cases, the care plans did not address self-administration, and there were no physician orders authorizing it, leading to a failure to ensure drugs and biologicals were properly stored and managed.