Failure to Secure and Properly Label Medications
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and properly labeled and dated, as required by professional standards. During observations on two separate occasions, a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and two tubes of zinc oxide silicone cream were found in a mauve basin on top of a resident's personal refrigerator in her room. These items, used for wound care and as barrier creams, were not secured in the medication cart as per facility policy. Interviews with the RN, Administrator, and DON confirmed that these medications should not have been left in the resident's room and should have been stored securely with appropriate labeling. The resident involved had chronic kidney disease, high blood pressure, bipolar disorder, moderate cognitive impairment, impaired vision, and was dependent on staff for several activities of daily living. Her care plan required medications to be provided as ordered, and her medication orders included wound care and barrier cream applications. Facility policy specified that medications and biologicals must be stored safely and securely, accessible only to authorized personnel. The failure to follow these procedures was confirmed through staff interviews and review of facility policy.