Failure to Secure and Properly Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, and that only authorized personnel had access to these medications. Multiple residents were found with medications at their bedside, including prescription and over-the-counter drugs, despite facility policy and staff statements indicating that residents were not permitted to self-medicate. These observations were made during interviews and direct observation of the residents and their rooms. One resident with a history of sepsis, hypertension, and chronic obstructive pulmonary disease was observed with a nebulizer and an ampule of Ipratropium-Albuterol Inhalation Solution at her bedside. The resident self-administered a breathing treatment, stating that she usually kept the ampule in her pocket. The nurse confirmed that the resident was not allowed to self-medicate and that nursing staff were responsible for administering such treatments due to the need for monitoring and potential side effects. Other residents were found with various medications at their bedsides, including medicated ointments, eye drops, antacids, magnesium hydroxide, and vitamins. Some of these residents were moderately cognitively impaired, and their care plans did not authorize self-administration of medications. The facility's policy required all drugs and biologicals to be stored securely and only accessible to authorized staff. The administrator confirmed that no residents in the facility were permitted to self-medicate and that nursing staff were responsible for medication administration and monitoring. Despite this, medications were found unsecured in resident rooms, and staff interviews confirmed that these practices were not in line with facility policy.