Failure to Secure Medications and Improper Storage in Medication Refrigerator
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly labeled and securely stored, as required by professional standards. During initial resident screenings, multiple residents were found with medications at their bedside, including prescription and over-the-counter drugs, without physician orders or completed self-administration evaluations. For example, one resident with COPD and sleep apnea had both an inhaler and a topical cream left on the over-bed table, and another resident with severe cognitive impairment had opened bottles of joint support capsules, Gas-X, and Aspercream accessible on the bedside table. A third resident with dementia and visuospatial deficits was observed with a bottle of Tums at the bedside. In each case, the residents did not have orders to self-administer medications, nor had they been evaluated for their ability to do so, and the medications were not secured as per facility policy. Additionally, the facility failed to maintain proper storage of medications and biologicals in medication refrigerators. Surveyors observed that alcoholic beverages, specifically bottles of wine and beer, were stored in a medication refrigerator alongside resident medications. The facility's policy explicitly prohibits the storage of non-medication items, such as food or beverages, in medication refrigerators. Despite this, the alcoholic beverages remained in the refrigerator during subsequent observations. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the presence of medications at the bedside without proper authorization and the storage of non-medication items in medication refrigerators were not in accordance with facility policy. Staff acknowledged that it was their responsibility to ensure medications were secured and that only medications should be stored in designated medication refrigerators.