Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by policy. For one resident with moderate cognitive impairment and multiple diagnoses, including heart failure and diabetes, a bottle of wound cleanser and a container of non-prescribed buttocks powder were observed left on the bedside dresser on multiple occasions. The resident's care plan required staff to administer medications as prescribed, and there was no order for the buttocks powder. Despite previous discussions with the resident's family, these items remained accessible at the bedside. Another resident, who was cognitively intact and at risk for substance abuse, was found with artificial tears on his bedside table. There was no physician order for these eye drops, and the resident reported self-administering them as needed. Nursing staff were unsure if this resident was authorized to self-administer medications, and the DON confirmed that neither resident had been assessed for self-administration. Facility policy required that only authorized staff have access to medications, and that medications be stored in locked areas, but these procedures were not followed for the two residents.