F0689

D

Resident Ingests Staff Medication Left in Pocketbook at Nursing Station

Spring House, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent an accident hazard when a resident with multiple cognitive and psychiatric diagnoses obtained and ingested a staff member’s prescription medication that had been stored at the nursing station. The resident had diagnoses including CHF, epilepsy, schizophrenia, intellectual disability, cognitive communication deficit, anxiety, and psychosis. A nursing note documented that early in the morning a nurse aide reported her pocketbook missing from the nursing station; the resident was later found in possession of the pocketbook and other personal belongings. It was discovered that the resident had ingested Zofran 4 mg tablets that were in the aide’s pocketbook, and empty blister packs from the Zofran prescription were found in the trash can in the resident’s room.

During an interview, the licensed nurse confirmed that she had been in the medication room when the aide reported the missing pocketbook and that the aide stated she knew the resident had taken it because the resident was “just taking things.” The nurse and aide located the resident in either the dining room or the resident’s bedroom and retrieved the pocketbook, after which the aide reported that her keys, money, and Zofran were missing. The resident denied taking the pocketbook, money, keys, and medication, and at one point opened her mouth and said, “Mommy look,” but nothing was seen in her mouth. The Nursing Home Administrator confirmed that staff are expected to keep personal belongings in the employee break room in the basement and not at the nursing station, indicating that the aide’s storage of her pocketbook with prescription medication at the nursing station constituted a violation of facility expectations and contributed to the accident hazard.