Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored in locked compartments or otherwise secured, as required by professional standards. During observations, surveyors found that a nasal spray belonging to a male resident with moderate cognitive impairment and chronic obstructive pulmonary disease was left on the resident's side table in his room. There was no physician's order for the nasal spray, no assessment for self-administration, and no documentation indicating the resident was competent to manage his own medications. The nasal spray was accessible to the resident and not secured as required. Additionally, a female resident with severe cognitive impairment and protein-calorie malnutrition was observed with a tube of zinc oxide left on her side table. The resident was unable to communicate clearly, and staff assigned to her care did not notice the medication was left at bedside. The physician's order indicated the barrier cream was to be applied as needed, but it was not secured after use. Similarly, a male resident with moderate cognitive impairment and incontinence was found with a tube of zinc oxide on his side table. The staff member responsible for his care could not recall if she had put the cream away after use, and the medication was left accessible in the resident's room. Interviews with staff, including CNAs, an LVN, the DON, and the Administrator, confirmed that medications such as nasal sprays and zinc oxide should not be left in resident rooms and should be stored in locked carts or otherwise secured. The facility's policy also required medications to be stored in a locked medication room or secured after administration. The failure to secure these medications resulted in them being left in plain view and accessible to residents, contrary to facility policy and professional standards.