Improper Medication Storage and Handling in Resident Rooms
Penalty
Summary
Facility staff failed to properly store medications for two residents, resulting in drugs being left unsecured in resident rooms and used inappropriately. For one resident with severe cognitive impairment and a diagnosis of Alzheimer's disease and unspecified dementia, a medication aide used Nystatin powder that had been left on the toilet in the resident's bathroom, rather than obtaining it directly from the medication cart. The aide admitted to using the powder found in the room and not bringing it in from the cart prior to care. The Director of Nursing confirmed that medications should not be stored in resident rooms or used if not brought in for the specific procedure. In another instance, a resident with moderate cognitive impairment and a history of mental health conditions had a medication cup containing cream left on the bedside table in their room. The resident did not have an order to self-administer medications, nor was there an assessment for self-administration. Staff interviews revealed that the night shift nurse routinely placed Nystatin cream in a cup on the bedside table for use by the next nurse, rather than storing it securely. The nurse who applied the cream discarded the cup left in the room and confirmed that medications should not be stored in resident rooms. Both incidents were observed by surveyors and confirmed through staff interviews. The facility did not have a medication storage policy in place at the time of the survey, contributing to the improper storage and handling of medications for these residents.