F0761

D

Unsecured Topical Medication Left at Bedside and Ingested by Resident

Owasso, Oklahoma Survey Completed on 02-02-2026

Penalty

Fine: $12,735

Summary

The deficiency involves the facility’s failure to secure and properly store medications, resulting in a cognitively intact resident having access to zinc oxide paste at the bedside. A physician’s order directed that zinc oxide 20% external paste be applied topically to the resident’s sacrum and buttocks every shift for skin integrity, and nursing documentation noted a stage II pressure ulcer on the coccyx with surrounding redness that was treated with zinc cream and a padded dressing. Despite this being a topical medication, it was left unattended at the resident’s bedside rather than stored in a locked compartment as required.

A subsequent nurse’s progress note documented that when the nurse entered the resident’s room, the resident was observed mixing zinc oxide paste into their oatmeal and confirmed having eaten some of the mixture. The resident’s comprehensive assessment showed a BIMS score of 15, indicating they were cognitively intact, and noted the use of ointment or medication applied to body areas other than the feet. Facility staff, including the MDS coordinator and ADON, later acknowledged that zinc oxide paste had been left at the bedside and that it was inappropriate to leave medications unattended for this resident, and they were unable to determine which staff member had left the cream there.