F0761

D

Unsecured Bedside Medications and Lack of Self-Administration Orders

Glendale, Arizona Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications and biologicals were properly stored and not left unattended at the bedside, and failure to follow its own self-medication policies. During an observation of one resident’s room, two containers of ZAL cream with pharmacy labels were found on the counter next to the sink, with no lockbox present. The resident reported that she had been self-applying the ZAL cream to her buttocks and labia since admission, that staff were aware she was using it, and that one container was empty. Review of the clinical record from admission through the observation dates showed no provider orders for ZAL cream and no orders authorizing self-administration of any medications or treatments.

The resident had diagnoses including Sjogren syndrome, urinary tract infection, and Type 2 diabetes mellitus, and an admission assessment showed she was alert and oriented, with a BIMS score of 13 indicating she was cognitively intact. The care plan included focuses on altered skin integrity and an indwelling catheter but did not include any focus or interventions related to self-administration of medications or treatments. Although provider orders were later written for a compounded topical preparation and ZAL cream, there was no evidence of any order permitting these medications to be stored at the bedside or self-administered by the resident during the period reviewed.

A subsequent room observation found a container of ZAL ointment and a box of Baqsimi (glucagon) on the sink counter, again without a lockbox. Staff interviews revealed inconsistent understanding and implementation of facility policy: a CNA stated that medications and creams should not be left at the bedside and should be reported to the nurse, while an LPN stated that ointments could be left at the bedside only if there was a provider order for self-administration, and confirmed there were no such orders for this resident. The LPN acknowledged that Baqsimi should have been kept in the medication cart and that he had not been aware these medications were in the room. The DON stated that residents requesting to self-administer must be assessed using a Self-Medication Administration Assessment form, require a provider order, and that medications must be kept in a lockbox; review of the record showed no such assessment or orders for bedside storage or self-administration, despite the presence of ZAL cream and Baqsimi in the resident’s room. Facility policies required medications to be administered only on clear provider orders and required staff to remove any unauthorized medications found at the bedside, which had not occurred in this case.