F0689

D

Unsecured OTC Medications, Razors, and Failed Elopement Prevention

Tucker, Georgia Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep resident rooms free of accessible accident hazards, specifically unsecured over-the-counter (OTC) medications and shaving razors, and failure to adequately secure and monitor exit doors to prevent an elopement. Facility policy F 689 Accidents requires the environment to be as free from accident hazards as possible and calls for ongoing identification of safety risks, QAA/Safety Committee evaluation of hazards, and implementation and monitoring of interventions. The facility’s wandering/unsafe resident policy requires assessment of at-risk individuals, care plan identification of elopement risk, and inclusion of safety interventions. Despite these policies, surveyors observed multiple instances where hazardous items were accessible in resident rooms and where an at-risk resident was able to leave the building unsupervised.

One cognitively intact resident with a seizure disorder, schizophrenia, depression, hypertension, and multiple prescribed medications, including anticoagulant and antiepileptic drugs, was found with two bottles of brand-name cold and flu OTC medication on a shelf at the foot of the bed. One bottle was nearly empty and the other half full, indicating prior use. The medications were unsecured and accessible. The resident reported he had purchased the cough medication himself because he felt the amount provided by the facility was not enough and that he took more of the medication because it worked for his cough. A nursing progress note documented that the resident had the cold medication in his room without a physician’s order and had been taking it at his discretion. The DON later stated that OTC medications should not be accessible to residents, except for an inhaler after assessment, due to concerns that residents, wandering residents, or visiting children might take them or that residents might not know how much to take.

Two other residents were found with unsecured shaving razors accessible in their rooms. One resident with severe cognitive impairment, vascular dementia, visual loss in both eyes, difficulty walking, muscle weakness, and dependence on staff for wheelchair mobility had several shaving razors in a clear plastic bag on top of the bedside nightstand. The resident stated the razors belonged to him and that he used them, which is why they were present in the room. Another cognitively intact resident with hemiplegia/hemiparesis, contractures, difficulty walking, and need for assistance with personal care had a shaving razor in a cup on top of a dresser adjacent to the bed. This resident reported shaving independently and also shaving his head. The Unit Manager RN confirmed the presence of razors in both rooms and acknowledged they were a safety concern. The DON stated that residents are assessed on admission for ability to use razors and may keep them only if they are in an enclosed bag, out of reach, inside the nightstand, and care planned for their use, conditions that were not met in these observations.

The facility also failed to prevent an elopement for a resident with dementia, depression, restless legs syndrome, and recent wandering and exit-seeking behaviors. A behavioral health evaluation documented wandering behaviors and difficulty redirecting the resident, and a care plan conference noted that the resident had been having exit-seeking behaviors requiring frequent redirection. The resident’s care plan identified a behavior problem related to walking the halls with belongings and refusing to return them to her room, and a subsequent care plan problem documented that she was at moderate to high risk for elopement, currently wandered, packed belongings to go home, and stayed near exit doors. Interventions included lodging on a secure unit and use of a wanderguard on the right wrist, with orders to check placement each shift and document its location.

Despite being on a locked unit with exits that were supposed to be locked, staff interviews revealed that during an electrical outage associated with sprinkler system servicing, the resident was able to leave the building. An LPN reported that the resident went out the front exit during the outage. A CNA described walking by an exit door, feeling a breeze, and noticing the door was open. He checked a gate outside that door but could not open it and suspected the resident had used an alternate door near the activities area with a ramp. He then went to notify the RN and ran to the street, where he saw the resident crossing five lanes of traffic and continuing to walk several houses down from a visible house near the facility. The CNA stayed with the resident until assistance arrived. He stated that the resident exit sought daily, constantly went to the doors shaking them, and always had her bags packed and at the door. The DON and Administrator confirmed that sprinkler system testing had affected the power and that doors had been open while staff were conducting fire watch, during which time the resident was able to elope.