Unsecured Medications and Unauthorized Bedside Inhalers
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in locked locations and to prevent medications from being left unattended, contrary to facility policy and professional standards. Surveyors observed multiple instances where medication cards and medication bottles delivered by the pharmacy were left on the nurse’s station desk and on top of a treatment cart for an extended period without any staff present or in line of sight, while residents and visitors walked past the area. The treatment cart was not in use and was positioned in front of the nurse’s station counter, making the unsecured medications easily accessible. Staff later confirmed that medications were not to be left unlocked or unattended and acknowledged that the medications had been left out since delivery because staff had not yet put them away. Additional observations showed that both the treatment cart and the medication cart, which contained medications, were left unlocked and unattended at the nurse’s station on another occasion, again with no staff in the area or in line of sight. Nursing staff, including an LPN and an RN, stated that medication and treatment carts should always be locked when unattended and that medications should never be left unattended at the nurse’s station or on carts. The DON and the Administrator both stated that staff were expected to lock medication and treatment carts when unattended and to secure medications with a lock upon receipt from the pharmacy, consistent with facility policies on medication labeling, storage, and administration. The facility also failed to secure medications for one resident by allowing prescription inhalers to remain at the bedside without appropriate orders or assessment for self-administration. A resident recently admitted with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, and acute respiratory failure reported having inhalers at the bedside that they self-administered and had brought from home. Observation revealed four prescription inhalers lying on top of the bed covers at the foot of the resident’s bed. Review of physician orders showed an order for a fluticasone furoate inhaler but no orders for tiotropium or albuterol inhalers and no order permitting bedside self-administration. Nursing leadership stated they were unaware of the inhalers at the bedside, confirmed that residents must be assessed and have an order to self-administer medications, and stated that even with such an order, medications should be kept in a secure location rather than on the bed. The Medical Director stated that all medications should be secured behind at least one locked door or drawer.
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