Failure to Secure Medications Results in Cognitively Impaired Resident Accessing Antifungal Powder
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a BIMS score of 3, indicating significant cognitive impairment, was found in possession of a facility-supplied bottle of antifungal (Miconazole) powder. The resident, who required supervision for eating, bed mobility, transfers, and moderate assistance with toileting hygiene, was observed by a housekeeper and a state tested nursing assistant (STNA) with the bottle up to her mouth, and the bottle appeared to be half empty with water mixed into the powder. The staff immediately removed the bottle from the resident and brought it to an LPN, who reviewed the ingredients and disposed of the bottle without further assessment or notification to other staff or the resident's physician or family. The LPN did not visit the resident's room initially, relying on the information provided by the housekeeper and STNA, and did not observe any powder residue or symptoms in the resident. The incident was not reported to the oncoming nurse, the physician, or the resident's family at the time. The facility's Director of Nursing (DON) only became aware of the incident the following day after being informed by another nurse that the resident's daughter had learned about the ingestion from a housekeeper. An investigation revealed that neither the resident nor her roommate had a physician's order for the antifungal powder, and the source of the bottle in the resident's possession could not be determined. Facility review of the antifungal powder's labeling and the Material Safety Data Sheet (MSDS) indicated that ingestion required immediate medical attention or contact with poison control, and the product was to be stored securely. The failure to ensure that medications and biologicals were appropriately secured and stored resulted in a cognitively impaired resident accessing and potentially ingesting a medication without an order, in violation of accepted professional principles and facility policy.