Unsecured Medication Found 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, a nasal spray was found on top of a resident's side table in plain view. The resident, who was cognitively intact and had a terminal prognosis related to hepatic malignancy, reported that the nasal spray was obtained during a prior hospital admission and had remained on his side table. Record review confirmed there was no physician order for the nasal spray, no assessment for self-administration, and no documentation indicating the resident was permitted to self-administer medications. Interviews with nursing staff and facility leadership confirmed that medications should not be kept in residents' rooms unless there is a documented assessment and order for self-administration. Staff acknowledged that the presence of the nasal spray in the resident's room was not noticed during routine rounds, and there was no indication that the medication had been brought in by family or authorized for use. The facility's policy requires that medications be stored securely and only accessible to licensed nursing or authorized personnel, which was not followed in this instance.