Failure to Secure Medicated Cream in Locked Storage
Penalty
Summary
Facility staff failed to store a medicated skin protectant in accordance with state and federal regulations requiring all drugs and biologicals to be kept in locked compartments accessible only to authorized personnel. During an observation, a tube of skin protectant containing zinc oxide was found on top of a resident's side table, accessible to the resident, who had severe cognitive impairment as indicated by a BIMS score of 00 and was incontinent for bowel and bladder. The resident's care plan included the use of barrier cream after each incontinent episode, and a physician's order authorized its application as needed. Interviews with staff, including a CNA, ADON, DON, and the Administrator, confirmed that the skin protectant should not have been left in the resident's room and should have been secured in a locked cart after use. The facility's policy required all drugs and biologicals to be stored in locked compartments, accessible only to licensed nursing personnel. The failure to secure the medicated cream was directly observed and acknowledged by multiple staff members as not meeting facility policy or regulatory requirements.