Unsecured Medications Found at Bedside Without Self-Administration Authorization
Penalty
Summary
Facility staff failed to ensure the safe storage of medications for one resident. During an observation in the resident's room, four prescription medications were found unsecured inside the nightstand, within reach of the resident. The medication bottles were not labeled for self-administration and were not stored in a locked medication cart or secured drawer. The resident reported taking the medications independently, without supervision. Review of the resident's records indicated that the resident had intact cognition, required moderate assistance with activities of daily living, and had diagnoses including diabetes mellitus and hypertension. There was no completed self-administration assessment or physician order permitting the resident to self-administer medications. The Assistant Director of Nursing confirmed that facility policy did not allow residents to keep medications at their bedside or self-administer medications without proper assessment and documentation. The presence of multiple medications at the resident's bedside and the resident's unsupervised administration were acknowledged as unacceptable and not in accordance with facility policy. Review of facility policies indicated that all medications and biologicals were to be stored in locked compartments, accessible only to authorized personnel, and administered only by licensed or permitted staff.