Unsecured Medication Left in Resident Room
Penalty
Summary
A medication used to treat hemorrhoids was observed unsecured on a bureau in a resident's room over a period of three days. The facility's policy requires that all medications, including those for external use, be securely stored in a locked cabinet, cart, or medication room inaccessible to residents or visitors. The resident involved had severe cognitive impairment, as indicated by a low score on the Brief Interview of Mental Status, and was admitted with diagnoses including unspecified dementia, mixed incontinence, and type 2 diabetes mellitus. Multiple observations by the surveyor confirmed the presence of the large tube of hemorrhoid cream in the resident's room, and review of the resident's physician's orders did not show an order for this medication. Interviews with facility staff, including the Unit Manager and Assistant Director of Nursing, confirmed that all medications and treatments should be kept in locked storage and not in resident rooms, regardless of whether the medication is facility stock or brought in by family. Staff acknowledged that the tube of hemorrhoid cream was left out in the open and should have been removed, and that the resident did not have an order for its use. The failure to secure the medication and ensure it was not accessible to the resident constituted a violation of the facility's medication storage policy and professional standards of practice.