Medication Error: Unattended Topical Medication at Bedside
Penalty
Summary
A medication error occurred when a medication cup containing zinc oxide cream was left unattended on a resident's bedside table. The resident, who had moderate cognitive impairment and required substantial assistance with activities of daily living, was unaware that the cream was present. The zinc oxide cream was prescribed to be applied to the resident's sacral coccyx area for skin maintenance. The nurse responsible for administering the medication stated she had prepared the cream but left it at the bedside while waiting for a CNA to finish cleaning the resident, acknowledging that it was not acceptable to leave the medication unattended. Facility policy required all medications to be stored securely and to be inaccessible to residents or others passing by. Both the nurse and the Director of Nursing confirmed that medications should never be left unattended, as this could result in accidental ingestion or use by residents. The facility's policies on medication storage and administration emphasized the importance of safe and timely administration, with medications only visible to the personnel administering them and not accessible to residents.