Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
Surveyors identified that the facility failed to ensure safe administration and storage of medications for four residents. Multiple medications, including albuterol inhalers, DuoNeb solution, Afrin nasal spray, pain relief ointments, miconazole powder, Dakin's solution, and Adapt stoma powder, were found at the bedsides of these residents. In each case, there was either no physician's order, no completed self-administration of medication assessment, or both, to authorize the residents to self-administer or store these medications at their bedside. For one resident with respiratory failure and moderately impaired cognition, an albuterol inhaler and DuoNeb solution were left at the bedside, and the resident was unsure of their prescribed medications. Although there was a physician's order to keep the inhaler at the bedside, the required self-administration assessment had not been updated to reflect this. Another resident with pneumonia and moderate cognitive impairment had Afrin nasal spray at the bedside without a physician's order or self-administration assessment. Similarly, a resident with lymphedema and moderate cognitive impairment had an albuterol inhaler at the bedside without the necessary documentation. A fourth resident, who had intact cognition and multiple diagnoses including spinal cord dysfunction and a pressure ulcer, had several topical medications at the bedside. There was no physician's order or self-administration assessment for these medications. In all cases, the Director of Nursing confirmed that the required assessments and orders were missing, and that medications should not have been left at the bedside without proper authorization and documentation.