Unsecured Medication Ointment Left in Resident Room
Penalty
Summary
A deficiency occurred when a medication cup containing a pink ointment, identified as calmoseptine ointment, was found unsecured and unattended on top of a dresser in a resident's room. The resident had severe cognitive impairment, was unable to make decisions, and required staff assistance for activities of daily living. There were no physician orders for the resident to self-administer medications. During observations and interviews, nursing staff acknowledged the ointment was likely used for the resident's skin care, but did not remove it from the room or secure it. Certified nursing assistants interviewed were unaware of the ointment's presence or use, and one stated she did not use any cream during care. Further interviews with licensed nursing staff and the Director of Nursing confirmed that all treatments, including ointments, were supposed to be stored in a locked treatment cart and only accessed by authorized personnel. The facility's policy required drugs and treatments to be administered only upon a licensed provider's order and to be securely stored. The failure to secure the ointment and restrict access to authorized personnel constituted a breach of the facility's medication storage protocols.