Medications Left Unsecured at Bedside of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments and accessible only to authorized personnel, resulting in a resident having medications left at the bedside. The facility’s undated Storage of Medications policy stated that medications were to be stored in locked compartments, in their original packaging, and that only persons authorized to prepare and administer medications should have access to them. Review of a quarterly MDS for Resident #47, with an Assessment Reference Date of 10/29/2025, showed a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. During observation of Resident #47’s room on 01/21/2026 at 12:40 PM, surveyors noted a white pill on the floor split in two next to a medication cup labeled with Resident #47’s name, and a second medication cup, also labeled with the resident’s name, containing a white pill on the bedside table. In interviews, the LPN confirmed the pills and medication cups were in the resident’s room, stated that the medications should not have been left at the bedside, and reported that the resident did not have the mental capacity to self-administer medications; the DON also acknowledged that the medications should not have been left at the bedside in unlocked, unattended medication cups. These observations and interviews demonstrate that the facility did not follow its own medication storage policy and allowed a moderately cognitively impaired resident unsupervised access to medications in the room, contrary to requirements that only authorized staff have access to drugs and biologicals and that such items be stored in locked compartments.
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