Medications Left Unsecured at Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments accessible only to authorized personnel, as required by regulation. During an observation, a bottle of Ayr Nasal Solution and biotene dry mouth moisturizing spray were found on the bedside table of a male resident with a diagnosis of diastolic (congestive) heart failure. The resident's care plan indicated he was unable to safely self-medicate and required 24-hour nursing care, and there was no order or assessment in place for self-administration of medications. The resident's cognition was intact, but he had a communication problem related to unclear speech. Interviews with the DON and ADON confirmed that the resident had not been evaluated for self-administration of medications and that no residents in the building were permitted to self-medicate. Both the DON and ADON acknowledged that medications should not be left at the bedside and should be stored in the nurse's cart. The facility's policy required medication rooms, carts, and supplies to be locked or attended by authorized personnel. The presence of medications at the resident's bedside was not detected by staff prior to the surveyor's observation.