Accessible Hazardous Substances and Medications in Dementia Unit
Penalty
Summary
Surveyors observed that on the second floor, a locked dementia care unit, a resident's bedside table contained a bottle of over 30 multivitamin tablets and a 16-ounce bottle of 91% isopropyl alcohol, both accessible to the resident. The resident, who has a diagnosis of dementia, anxiety disorder, and type 2 diabetes, was unable to identify the pills or the alcohol, mistaking the alcohol for water. The resident's care plan documented short and long-term memory loss and included interventions to ensure safety, but there was no care plan or physician order permitting self-administration of medication. Staff interviews confirmed that the LPN was unaware of how the items came to be at the bedside and stated that the resident should not have access to either the alcohol or the vitamins. The DON also confirmed that no medication or alcohol should be accessible to residents on the dementia unit. The presence of these items in the resident's room, without staff knowledge or appropriate care planning, constituted a failure to maintain an environment free of accident hazards.