Improper Storage of Barrier Cream Left Accessible at Bedside
Penalty
Summary
The facility failed to store medications and biologicals in locked compartments and under proper controls, and failed to limit access to medications to authorized personnel, as required by State and Federal laws and facility policy. A resident with dementia, hemiplegia, hemiparesis, and moderate cognitive impairment (BIMS score of 09), who was incontinent of bowel and bladder and care planned to remain free from skin breakdown, was observed in bed with a tube of barrier cream left on the bedside table. The cream was visible and accessible to the resident and others in the room. The resident reported that staff used the cream when cleaning and changing her and that some staff sometimes left the tube on her side table. During subsequent observations and interviews, an LVN stated she did not know who left the barrier cream in the room and acknowledged that the tube should have been stored in the treatment cart or otherwise out of the resident’s reach. She indicated that residents might use the cream more than recommended or, if confused, might consume it. The ADON stated that medications should not be stored in residents’ rooms and that the tube of wound dressing cream should have been in the nurse’s cart and not within reach of any resident. The Administrator similarly stated that staff were expected to look around residents’ rooms for any medications, as residents could consume or use medications inappropriately if left at bedside. Review of the facility’s Medication Labeling and Storage policy reflected that all medications and biologicals were to be stored in locked compartments, which was not followed in this instance.
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