Unsupervised and Unsecured Medications Left at Bedside
Penalty
Summary
Facility staff failed to ensure medications were properly stored and labeled, resulting in drugs being left unattended at the bedside for two residents. For one resident who was cognitively intact, required assistance with daily care, and had diagnoses including heart failure, anxiety, and depression, surveyors observed an unsupervised medicine cup containing twelve unlabeled pills on the overbed table while the resident was lying in bed. The resident reported that she was aware the pills were there and that nurses frequently left her pills sitting on the table. The LPN responsible acknowledged that he had left the medications in the room because he believed the resident would take them after eating breakfast and confirmed he did not remain in the room to observe medication administration, contrary to the facility’s medication administration policy that staff should not leave medications or chemicals unattended. For another cognitively intact resident who required assistance with daily care and had diagnoses including noninfective gastroenteritis and colitis, physician orders directed the use of triamcinolone 0.1% cream to the back and hips twice daily for dermatitis. During observation, surveyors found a box of triamcinolone 0.1% cream left on the bottom left side of the resident’s bed near the door, unsupervised by staff. The Assistant DON confirmed in both cases that medications and topical prescription products should not have been left unsupervised in the residents’ rooms, indicating noncompliance with the facility’s policy and state requirements for pharmacy and nursing services regarding proper labeling and secure storage of drugs and biologicals.
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