Unsecured Medication Found at Bedside Without Self-Administration Order
Penalty
Summary
Surveyors identified a deficiency in the facility's medication storage practices when a Fluticasone inhaler prescribed for a female resident with a history of acute respiratory failure, COPD, pneumonia, heart failure, and morbid obesity was found unsecured on the resident's nightstand. The resident was alert, oriented, and receiving oxygen therapy at the time of observation. There was no physician's order for self-administration of the inhaler, nor was there a documented assessment for the resident's ability to self-administer medications. Multiple staff interviews confirmed that medications should not be left in resident rooms unless there is a specific physician order for self-administration, which was not present in this case. Staff members, including medication aides and nurses, were unable to explain why the inhaler was left at the bedside and acknowledged that only authorized personnel should administer medications. The Director of Nursing also confirmed that medications should not be left at the bedside without proper orders and assessment. A review of the facility's medication storage policy indicated that all drugs and biologicals must be stored in locked compartments and that nursing staff are responsible for maintaining safe and secure medication storage areas. The failure to secure the inhaler and ensure only authorized access to medications was found to be inconsistent with both facility policy and regulatory requirements.