Unsecured Medications and Topical Agents Left Accessible in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free from accident hazards by allowing unsecured medications to be accessible on two nursing units. Facility policies on administering medications and self-administration of medications require that medications be administered safely, only as prescribed, and that any medications permitted for self-administration be stored securely and not accessible to other residents. The policies also state that if safe storage in the resident’s room is not possible, medications must be stored on a central medication cart or in the medication room. Despite these policies, surveyors observed multiple instances where medications and medicated products were left unsecured in resident rooms. For one resident who was cognitively intact and had been assessed and approved for self-administration, surveyors observed an orange oblong pill partially obscured by papers on the bedside table. The resident stated the pill must have fallen out of her medication cup, and an LPN later identified and secured it as methocarbamol 750 mg, for which there was a current physician’s order. In another room, surveyors observed two pills and a clear medication cup on the floor near a bed. An LPN confirmed the medications should not have been on the floor and secured them. The Nursing Home Administrator later identified these pills as Eliquis 5 mg and sertraline 100 mg. For another cognitively intact resident, surveyors found a tube of hydrocortisone 1% cream at the bedside. The tube lacked instructions for use, dosage information, and labeling, and there was no physician order in the clinical record for this medication. A RN Supervisor confirmed the resident should not have had the hydrocortisone cream at the bedside. For a third cognitively intact resident, surveyors observed a tube of zinc oxide 20% ointment at the bedside, labeled with the resident’s name and room number. The resident reported that staff routinely left the ointment at the bedside for application, that she did not apply it herself but could if she chose to, and that staff routinely left medications at her bedside. The Nursing Home Administrator was informed that medicated creams and ointments were being left at bedsides accessible to residents who had no documented assessment or approval to self-administer medications.
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