Improper Storage of Over-the-Counter Medication at Bedside
Penalty
Summary
A deficiency occurred when a resident was found to have a tube of BioFreeze, an over-the-counter topical analgesic, at her bedside table, accessible without staff supervision. The resident, an elderly female with diagnoses including hypertension, dementia, and cervical disc myelopathy, had a BIMS score indicating intact cognition but also had hand contractures that limited her ability to self-administer medication. There was no documentation in her care plan regarding her ability to self-administer medications, and no physician order was present for the BioFreeze. Multiple staff members, including CNAs and nursing leadership, were aware or became aware of the medication's presence but did not ensure its removal or proper storage according to facility policy. Interviews revealed that staff assumed nursing was aware of the medication, and the ADON had previously instructed a CNA to remove it but did not verify its removal. The DON confirmed that all medications, including over-the-counter products, require a physician order and must be stored securely in the medication cart. Facility policy states that only authorized personnel may administer medications and that self-administration must be specifically authorized by a physician. Despite these policies, the medication remained accessible at the resident's bedside, contrary to established procedures.