Failure to Securely Store and Administer Medications
Penalty
Summary
Multiple instances were observed where medications and biologicals were not securely stored according to facility policy and professional standards. In one case, a family member found a pink capsule and a white tablet on a resident's bed, which the resident stated were left by the night nurse. The resident reported that the nurse left the medication on the table and departed before ensuring the medication was taken, and that staff do not return even if called. The pills were later identified as melatonin, which was ordered, and Benadryl, for which there was no physician order. The resident's electronic medical record confirmed the absence of an order for Benadryl. Another resident was found with an inhaler left on top of an oxygen concentrator in their room. The resident stated the nurse left it for use as needed, but there was no physician order for self-administration, and the resident was not on a self-administration program. Additionally, insulin pens intended for another resident's son were found at a resident's bedside, and a cup containing eight pills was observed on a bedside table. Staff confirmed that these medications should not have been left at the bedside and that the residents were not authorized for self-administration. Further observations included medication and treatment carts left unlocked and unattended in the hallway, with staff acknowledging that carts should be locked when not in use or not in the immediate presence of a nurse. The facility's policy, last revised in 2018, requires that medications and biologicals be stored safely, securely, and only accessible to authorized personnel. These lapses in medication storage and administration practices were confirmed through staff interviews, resident statements, and review of medical records.