Failure to Secure Medications and Prevent Unauthorized Resident Access
Penalty
Summary
The facility failed to ensure proper storage and control of drugs and biologicals as required by state and federal regulations. One resident with moderately impaired cognition and a history of anticoagulant use was found to have a nasal decongestant spray at his bedside without an order for self-administration. The resident stated he kept the medication nearby for nosebleeds, referencing a physician's recommendation, but there was no documentation in his care plan or physician orders permitting self-administration. Facility staff, including the administrator and director of nursing, confirmed that residents are not allowed to keep medications in their rooms, and policies prohibit such practices unless specifically authorized by the care team. Additionally, staff failed to secure medication and treatment carts as required. Observations revealed that a medication cart on one hall and a treatment cart on the east wing were left unlocked and unattended by LVNs while they performed other tasks. Interviews with staff acknowledged the potential for unauthorized access to these carts, and facility policy mandates that carts must be locked when not in use and never left unattended. Facility records and policies reviewed during the survey confirmed that only authorized personnel should have access to medications, and that all drugs and biologicals must be stored in locked compartments under proper conditions. The facility's own admission materials and policies reinforce these requirements, stating that medications are not allowed in resident rooms except under specific circumstances with physician orders. Despite these policies, the survey found multiple instances of non-compliance involving both resident access to medication and unsecured medication storage by staff.