Medications Found Unsecured in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by state and federal regulations. During an observation, two medications prescribed to a resident—Labetalol HCl and Pantoprazole Sodium—were found on the floor, approximately 2-3 inches from the resident's bed. The resident in question was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15, and required partial to maximum assistance with activities of daily living. The medications were discovered by the resident's friend during a visit, who then notified a nurse on duty. Upon being informed, the nurse, who had just started her shift, retrieved the pills from the resident's room and identified them as the resident's morning medications. The nurse checked the medication administration record (MAR) and found that the medications had already been documented as administered, so she did not re-administer them. The nurse also checked the resident's blood pressure and documented the incident in the 24-hour report, as instructed by supervisory staff. However, a subsequent review of the 24-hour report book did not show any documentation of the incident involving the medications found on the floor. Interviews with facility staff, including the ADON and DON, confirmed that the incident was brought to their attention by the resident's friend and that an investigation was initiated to determine how the medications ended up on the floor. The facility's policy on the destruction of unused drugs was reviewed, but there was no evidence that the medications were properly secured or that the incident was fully documented according to policy. The failure to secure medications and ensure proper documentation constituted a deficiency in medication storage and handling.