Failure to Secure and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were safely stored and accessible only by authorized personnel. Physician orders and the Medication Administration Record indicated that a resident was prescribed Zenpep Oral Capsule Delayed Release Particles, with specific instructions for administration before meals and as needed with snacks. During an observation and interview, the resident was found to be in possession of multiple Zenpep capsules in a clear plastic medicine cup and reported self-administering the medication without notifying nursing staff or adhering to the prescribed schedule. Facility staff confirmed that the resident should not have had access to the medication and that nursing failed to ensure proper storage and administration as ordered.