Medications and Treatments Improperly Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and treatments at the bedside for Resident #46. The resident was admitted with diagnoses including left hand contracture, dysphagia, major depressive disorder, and muscle weakness, and had a BIMS score of 10 indicating moderate cognitive impairment. The care plan contained no documentation authorizing medications at the bedside. During an observation in the resident’s room, surveyors noted an overbed table covered with a disposable bed pad holding multiple items, including a clear resealable bag with gauze, an abdominal pad package, bandages, an opened 200-count package of 4x4 gauze sponges, three individually wrapped oral swabs, a silver wound dressing package, a small black tube with a white cap, an opened skin protectant packet, a spray bottle of Skintegrity wound cleanser, and a nearly full 16-ounce bottle of mineral oil labeled as a lubricant laxative. In interviews, an RN identified the black tube as Medihoney used for wound treatment and acknowledged that it, along with the skin protectant, should not be kept at the bedside, and was unsure whether the wound cleanser could remain in the room or if mineral oil was considered a medication. A CNA stated that no medications or treatment supplies are allowed to be left at the bedside. The regional interim DON confirmed that medications are not to be left at the bedside unless a self-administration assessment is completed, the physician is contacted, and the appropriate form is completed and signed, and further clarified that medications are anything administered to residents, including mineral oil. The DON was only aware of the wound cleanser being at the bedside and not the mineral oil, Medihoney, or skin protectant. Facility policies on Medication Storage, Medication Administration, and Self-Administration of Medications all required secure storage of medications, prohibited leaving medications at the bedside, and required documentation of interdisciplinary assessment and determination regarding bedside storage in the medical record and care plan, which had not been done for this resident.
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