Failure to Secure Medications in Locked Storage
Penalty
Summary
Surveyors identified that drugs and biologicals were not consistently stored in locked compartments as required by professional standards. Multiple residents were found with medications in their rooms, in plain view and accessible, without documented assessments for self-administration or physician orders permitting them to manage their own medications. For example, one resident with severe cognitive impairment and dementia had an anti-fungal powder on her overbed table, despite no assessment indicating she was competent to self-administer medications. Another resident, who was cognitively intact but had no physician order for Systane eyedrops, had three bottles of the eyedrops on her overbed table. A third resident with severe cognitive impairment had a nasal spray on her dresser, also without a physician order or self-administration assessment. Staff interviews confirmed that medications should not be kept in residents' rooms unless there is a documented assessment supporting self-administration. Nursing staff and administration acknowledged that the presence of medications in resident rooms was not in accordance with facility policy or professional standards. Staff also noted that medications left in resident rooms could be accessed by other residents, particularly those who are confused, and that there was no monitoring of medication use in these instances. Record reviews further revealed that there were no assessments for self-administration, no clear instructions for residents to self-administer, and no documentation of resident competency to manage their own medications. Facility policy required all drugs and biologicals to be stored in locked compartments and for nursing staff to be responsible for medication storage. The observed practices were inconsistent with these requirements, leading to the identified deficiency.