Unsecured Medications at Bedside and Nursing Stations
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in accordance with its own policy and accepted professional standards. The facility’s undated Medication Storage policy stated that, with the exception of emergency drug kits, all medications must be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. For one resident, identified as having acute respiratory failure with hypoxia, incomplete C5–C5 quadriplegia, dysphagia, and a Brief Interview of Mental Status score indicating moderate cognitive impairment, surveyors found hydrocortisone 2.5% cream and clobetasol propionate 0.05% cream in an open nightstand drawer at the bedside. Record review showed no assessment or physician order authorizing this resident to self-administer medications. Nursing staff, including an RN and a CNA, acknowledged during a side‑by‑side observation that the creams were kept at the bedside so the CNA could apply them during care. Additional unsecured medications were observed at both nursing stations. At one nursing station, surveyors observed two bottles of melatonin (3 mg and 5 mg, 200‑count) left on the nursing counter with no staff present and three residents nearby; the ADON acknowledged the medications had been left at the station, noting they were unopened. At another observation of the North nursing station, an enema saline laxative containing dibasic sodium phosphate 7 g and monobasic sodium phosphate 19 g was found unsecured with no staff present and four residents nearby. A RN Unit Manager confirmed that medications should be secured at all times and stated she did not know who left the enema at the station before removing it.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.