Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store drugs and biologicals in accordance with state and federal regulations, resulting in multiple instances where medications were left unsecured and accessible to residents. Specifically, tubes of zinc oxide, a medicated barrier cream, were found left in the rooms of three different residents. In each case, the zinc oxide was observed on top of dressers or side tables, within easy reach of the residents. For one resident, who was cognitively intact and always incontinent, the zinc oxide was left on his dresser and used by staff after each episode of incontinence. There was no assessment for self-administration or documentation that the resident was competent to manage his own medications. For two other residents, both with severe cognitive impairment and incontinence, tubes of zinc oxide and a container of wound cleanser were also found in their rooms, with no clear explanation as to why these items were not secured in the treatment cart as required. Additionally, surveyors observed a vial of solution for a breathing treatment left unattended on top of a nurse's cart in a hallway. The cart was facing the hallway and was not attended by staff, while residents and staff passed by. The nurse responsible for the cart acknowledged that she had left the medication unattended when called away, and recognized the risk that residents could access the medication. Facility staff, including CNAs, wound care nurses, the DON, and the ADON, all confirmed during interviews that medications, including medicated ointments and wound cleansers, should not be left in resident rooms or unattended on carts, as this could lead to improper use or ingestion by residents. Record reviews confirmed that facility policy required all medications and biologicals to be stored in locked compartments and not left unattended or accessible to residents. The policies also specified that only authorized personnel should have access to medications and that medications should not be kept on top of carts. Despite these policies, the observed actions and inactions of staff led to multiple instances where medications were not properly secured, resulting in a deficiency related to medication storage and access.