Failure to Ensure Proper Medication Storage and Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that medications were stored and administered according to physician orders and facility policy. Two residents with moderate cognitive impairment and diagnoses including dementia and other neurological conditions were found with medications left on their bedside tables. Neither resident was care planned or had a physician order to self-administer medications or to have medications at bedside. Observations and interviews confirmed that these medications, including both oral and topical forms, were accessible to the residents without appropriate authorization or supervision. Record reviews showed that the care plans for both residents specified that medications should be administered by staff as ordered by the physician. Despite this, medications such as aspirin, calcium carbonate, ferrous gluconate, and a topical muscle and joint cream were found in the residents' rooms. One resident expressed confusion about whether she had taken her medication, and a family member reported finding untaken medications left at the bedside on multiple occasions. Staff interviews consistently indicated that medications should not be left in resident rooms and that all medications must be administered by licensed personnel or medication aides. Facility policies and recent inservice training reinforced that medications are not to be left at the bedside and must be administered safely and as prescribed. The Director of Nursing and the administrator both stated that no residents were authorized to self-administer medications or have them at bedside, and that any such occurrences should be addressed immediately. The failure to follow these procedures resulted in medications being left unattended in resident rooms, contrary to facility policy and physician orders.