Unsecured Medication Found in Resident Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls for one resident. A tube of diclofenac sodium topical gel 1% was found unsecured on a desk in the room of a resident who had moderate cognitive impairment and no physician order for the medication. The resident was unable to recall how she obtained the gel. Interviews with medication aides and nursing staff confirmed that no residents in the facility were authorized to self-administer medications, and all medications should have been stored in medication carts or the medication room. The medication aide and RN were unaware that the resident had the topical gel in her possession, and the responsible party for the resident denied bringing any medications into the facility. Further interviews with the ADON, DON, and Administrator confirmed that facility policy required all medications to be stored securely and that no residents were permitted to self-administer. The facility's policy on medication storage, revised April 2007, stated that nursing staff were responsible for maintaining medication storage in a safe, secure, and orderly manner. The presence of the diclofenac gel in the resident's room indicated a failure to follow these procedures, as the medication was not stored in a locked compartment and was accessible to the resident.