Unsecured Medication Storage in Resident Room
Penalty
Summary
Facility staff failed to safely and securely store medications for one resident. During an observation, two vials of Ipratropium-Albuterol Inhalation Solution were found on the overbed table in the resident's room, with one vial opened and one unopened. The resident reported that nurses had left the medications for her and was unsure if there were more vials elsewhere. There was no individual medication storage cabinet in the room, and the Director of Nursing was unaware that medications were being stored unsecured in the resident's room. A review of facility policy indicated that medications and biologicals are to be stored safely, securely, and properly, accessible only to authorized personnel, and that bedside storage is only permitted with a prescriber's written order for residents able to self-administer. The resident had a BIMS score indicating no cognitive impairment and had an active physician order for the inhalation solution, but there was no physician order permitting storage of medications in the resident's room. Both the DON and Administrator confirmed that all medications were expected to be stored in locked medication rooms or carts.