Unsecured Medications Left at Bedside and Failure to Follow Medication Storage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and not left at the bedside unsupervised. For one resident with cerebral atherosclerosis, stage IV kidney disease, hypertension, impaired cognition, and a care plan addressing risk for skin breakdown, physician orders included triamcinolone acetonide cream applied twice daily to the lower legs for stasis dermatitis. During observation of this resident’s room, surveyors found a large tub of ointment and two bottles of roll-on Biofreeze with pharmacy labels left in the room. These medications were present without staff supervision, contrary to the facility’s policy that medications must be locked or attended by authorized personnel. For another resident with atrial fibrillation, COPD, chronic pain, and a care plan addressing pain management, physician orders included daily potassium chloride ER 20 mEq and hydrocodone-acetaminophen 7.5-325 mg every six hours for pain. During observation, this resident was alone in the room in a wheelchair with a lunch tray and a medication cup containing two oval white pills on the bedside table. The resident stated the pills were a pain pill and a potassium pill left for her to take with lunch. The hydrocodone-acetaminophen tablet, a narcotic, had not been signed out on the controlled substance count sheet at the time of observation. The facility’s own medication storage policy states that only licensed nurses or those lawfully authorized to administer medications may access them and that medications must be locked or attended by authorized persons, which was not followed in these instances.
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