Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored in locked compartments, as required by professional standards. During observations, it was found that a male resident with obesity and muscle weakness, who was cognitively intact and incontinent, had three bottles of nystatin powder and barrier ointment stored in a basket at his sink inside his room. The resident confirmed that these items had been in his room for some time, alongside personal care items, and that staff were aware of their presence. A female resident, also cognitively intact and incontinent, was found to have a tube of barrier ointment containing zinc oxide left on top of her table at the foot of her bed, visible from the hallway, while she was not present in the room. Staff interviews confirmed that medications, including medicated ointments and powders, should not be accessible in residents' rooms due to the risk of misuse. Staff acknowledged that these items should have been stored in medication carts or secured drawers, and that they were not aware of the presence of these medications in the residents' rooms until the surveyor's observation. The facility's policy on medication administration and management specifies that only authorized medical and licensed nursing staff are permitted to administer medications ordered by a physician. Despite this policy, the presence of nystatin powder and barrier ointment in residents' rooms indicated a lapse in adherence to proper medication storage protocols, as staff failed to remove or secure these items, allowing them to remain accessible to residents.