Improper Medication Storage and Unsanitary Equipment
Penalty
Summary
Facility staff failed to ensure that a resident's diclofenac cream medication was properly stored and secured according to facility policy. The resident, who had diagnoses including metabolic encephalopathy, muscle weakness, and anxiety disorder, was assessed as having severely impaired cognitive skills and was totally dependent on staff for activities of daily living. The resident was not considered safe for self-administration of medication. Despite this, the diclofenac cream was found in the resident's bedside table drawer, accessible to the resident, who was known to put random objects in his mouth. Both a nurse and the Director of Nursing confirmed that the medication should not have been at the bedside due to the resident's confusion and inability to self-administer medications. Additionally, a pill cutter assigned to one of the medication carts was observed to have whitish and orange particles, indicating it was not cleaned and sanitized as required. Nursing staff acknowledged that pill cutters were supposed to be cleaned before and after each use for infection control purposes. Facility policy required medications to be stored in locked compartments and medication preparation areas to be maintained in a clean, safe, and sanitary manner. The failure to properly store medication and maintain clean medication equipment was confirmed through observation, staff interviews, and review of facility policies.