Failure to Prevent Resident Access to Unsecured Medications
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by allowing a resident to keep multiple medications, including prescription and over-the-counter items, at their bedside without an assessment for self-administration or a physician's order permitting self-administration. The resident, who had a history of acute and chronic respiratory failure, pneumonia, and COPD, was observed with fluticasone nasal spray, saline nasal spray, triple antibiotic ointment, and eye drops on their bedside table. The resident reported having ordered and received these items independently and kept them within reach for personal use, without staff knowledge or documentation in the care plan regarding self-administration. Staff interviews confirmed that facility policy prohibits residents from keeping medications in their rooms unless specifically authorized by a physician and following a self-administration assessment. Multiple staff members, including a CNA, LPN, RN, and the DON, verified that medications should not be left at the bedside and that no residents in the facility were authorized to self-administer medications at the time. The presence of these medications in the resident's room was not identified or addressed by staff until observed during the survey, indicating a lapse in supervision and adherence to facility policy.