F0761

E

Improper Medication Storage and Use of Unordered Treatments

Evanston, Illinois Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely and used only in accordance with physician orders and facility policy. During wound care for R7, surveyors observed multiple topical medications kept at the bedside, including ketoconazole 2% cream, zinc oxide 4%, triamcinolone 0.1% ointment, and mupirocin 2% ointment. The Wound Care Nurse stated that treatment medications should not be kept at the bedside without a physician order but acknowledged that R7 requested to keep them there and that R7’s son had brought some medications from home. R7 reported that CNAs applied these medications to his buttocks after incontinence episodes and that his son also applied them during visits.

Record review for R7 showed active physician orders for mupirocin 2% cream and triamcinolone 0.1% cream for specific wound care sites and frequencies, but no orders for ketoconazole 2% cream or zinc oxide 4%. The DON confirmed that the ketoconazole and zinc oxide had been brought in by a family member and that residents could not keep treatment medications at the bedside without physician orders. R7’s comprehensive care plan documented that he resists care, refuses to follow physician orders and guidance, and believes his own treatment approaches are more beneficial than those recommended by health care professionals. He was identified as high risk for pressure sore development, with contributing conditions including arthropathic psoriasis and seborrheic dermatitis, but the care plan did not address his desire to keep medications at the bedside.

Surveyors also identified medication storage issues in the third-floor medication room refrigerator, where medications for several residents were stored with a broken thermometer and an incomplete temperature monitoring log for two months. An expired medication, Konvomep (omeprazole) 2-84 mg/ml, labeled as opened on 8/28/2025 and expired on 9/27/2025, remained in the refrigerator for one resident. The RN on duty stated he was unaware the thermometer was broken and that the night shift nurse completed the refrigerator log. Facility policies required medications to be secured in locked storage, to be administered only with written physician orders, to be stored at appropriate refrigerated temperatures with daily temperature logs, and for outdated or deteriorated medications to be immediately removed and disposed of, but these procedures were not followed in the observed instances.