Unlabeled Medication Cups Left at Bedside
Penalty
Summary
A deficiency occurred when three unlabeled medication cups containing white cream were found inside a white plastic container on top of a resident's dresser. The resident, who was cognitively intact and had a diagnosis including generalized muscle weakness, stated that the cups contained lidocaine cream brought in by a nurse and that it was applied to her hands twice daily. Multiple staff members, including two CNAs and a treatment nurse, confirmed the presence of the unlabeled cups and noted that the cream should not have been left at the bedside, especially without proper labeling. One CNA expressed concern that a confused resident might mistakenly ingest the cream, and the treatment nurse indicated the cream resembled barrier cream. The Director of Nursing, upon being shown a picture of the cream, acknowledged that it was unacceptable for licensed staff to leave creams or unknown substances at the bedside. A review of the facility's policy confirmed that drugs and biologicals are to be stored in locked compartments. The failure to properly label and securely store the medication at the resident's bedside constituted a breach of the facility's medication storage policy.