Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required, for two residents. Both residents were found to have medications in their rooms without proper authorization or assessment for self-administration. Specifically, one resident had a nasal spray and a cup with powder on her side table, and the other had Systane eye drops and antifungal powder at her bedside. Neither resident had a physician's order or care plan indicating they were permitted to self-administer these medications, nor was there an assessment documenting their ability to do so. Record reviews showed that both residents were cognitively intact, with BIMS scores of 15, and had various medical diagnoses including asthma, bipolar disorder, allergic rhinitis, and depression. However, their care plans did not include interventions or permissions for self-administration of medications. Additionally, there were no physician orders for the nasal spray or eye drops found in the residents' rooms, and no assessments had been completed to determine their capability for self-administration. During interviews, staff members acknowledged that medications should not be left in residents' rooms due to the risk of accidental overdose or misuse. Staff also confirmed that the medications observed should have been administered by nursing staff and not left accessible to the residents. The facility's policy requires all drugs and biologicals to be stored securely and separately from other substances, which was not followed in these instances.