Unsecured Medications and Chemicals Accessible to Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that medications and chemicals were secured and not accessible to cognitively impaired, independently mobile residents in the memory care unit. Observations revealed that a resident with severe cognitive impairment and impaired decision-making, who was independent with walking, was able to access a cubby in the day room without staff supervision. The resident was observed pulling back a curtain and looking into the cubby while other residents were present and no staff were in the room. The care plan for this resident indicated a tendency to touch various objects and directed staff to allow this only when safe, but staff were not present to supervise. Further review showed that a total of ten cognitively impaired, independently mobile residents were left unattended in the day room at multiple times. During one observation, the cubby was found to contain a staff member's bag with an almost full bottle of ibuprofen and a spray bottle of Old English furniture polish, both of which were accessible to residents. Facility policy required medications and chemicals to be locked and the environment to be free from such hazards, but these protocols were not followed, as confirmed by the DON during an interview.