Unsecured and Unordered Medications Found in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and that discontinued medications were not kept in resident rooms. For one resident, review of February 2026 physician orders and the medication administration record showed no current order or documentation for miconazole powder, yet surveyors observed three bottles of miconazole powder in the resident’s room. The DON confirmed that the miconazole powder had been discontinued and acknowledged that the medication should not have been stored in the resident’s room. For another resident, admitted with multiple diagnoses including COPD, Takotsubo syndrome, atherosclerotic heart disease, hypertension, hyperlipidemia, dorsalgia, depression, and GERD, the admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment with daily decision-making. Review of physician orders revealed no orders for ferrous sulfate 325 mg tablets, Ofloxacin otic solution 0.3%, Albuterol sulfate inhalation aerosol, or Ventolin HFA 90 mcg/actuation. However, observations of the resident’s room with an LPN showed a labeled bottle of ferrous sulfate tablets on the side table on one day, and Ofloxacin otic solution, Albuterol sulfate inhalation aerosol, and Ventolin HFA inhaler on the side table on another day, all with doses available. The LPN confirmed there were no orders for these medications or for them to be kept at bedside, and the DON was informed of these findings.
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