Failure to Secure Medications and Topical Treatments in Resident Rooms
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with state and federal regulations, resulting in multiple instances where medications and topical treatments were left unsecured in resident rooms. Surveyors observed wound cleansers, antiseptic skin cleansers, barrier creams, nystatin powder, and povidone-iodine sachets left in plain sight in the room of a cognitively intact female resident with multiple sclerosis and a surgical wound. There was no assessment for self-administration of medications, nor any documentation indicating the resident was competent to manage her own medications. The resident confirmed that the nurse performed her wound care and that no one had discussed the risks of having these items in her room. In another case, a female resident with dementia and moderate cognitive impairment was found to have a basket containing a squeeze eye drop bottle, hemorrhoid ointment, hydrocortisone ointment, and triple antibiotic ointment in her room. There were no physician orders for these medications, no assessment for self-administration, and no evidence the resident was competent to manage her own medications. The resident did not respond when asked about the medications, and staff later confirmed these items should not have been accessible. Additional observations included a cognitively intact female resident with no current wounds who had two containers of wound cleanser in her room, and another cognitively intact female resident with urinary and bowel incontinence who had sachets of skin barrier ointment left on her side table, including an open sachet with ointment residue. Staff interviews confirmed that medications and topical treatments should not be left in resident rooms unless a proper assessment for self-administration had been completed, and that these items should be stored securely to prevent misuse or accidental ingestion by residents.