Unsecured Medications Left in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s safe storage of medications when multiple residents were observed with unsecured medications at bedside. On two consecutive days, one resident’s room was observed to contain an unlocked bottle of Melatonin 10 mg gummies and a bottle of brand-name eye vitamin soft gels on the nightstand. Another resident’s room was observed on two days with an unsecured bottle of Allergy Nasal Mist (Oxymetazoline HCl 0.05% nasal decongestant) on the overbed table. A third resident’s room was observed on two days with an unlocked bottle of Antacid Extra Strength tablets, a box of Aspirin Pain Reliever/Caffeine/Pain Reliever Aid arthritis powder, and a bottle of vaporizing rub on the overbed table. Photographic evidence was obtained for each of these observations. In interviews, LPN staff members acknowledged that these medications should not have been stored in residents’ rooms and stated that medications should be locked in the medication cart at all times. The Assistant Director of Nursing stated that medications should not be in any resident’s room unless the resident has an order to self-administer, in which case they must be locked in a box in the room; otherwise, medications are to be locked in the medication cart. The Director of Nursing stated that medications should never be left in a resident’s room unlocked and should be locked at all times. Review of the facility’s “Medication Storage and Labeling” policy, issued 3/21 and revised 1/24, documented that all drugs and biologicals are to be stored in locked compartments, with compartments containing drugs and biologicals locked when not in use and unlocked medication carts never left unattended.
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