F0761

D

Improper Bedside Storage of Nystatin Powder

Arcadia, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to medication storage when a physician-ordered Nystatin powder for treatment of scrotal moisture-associated skin damage (MASD) was found stored at a resident's bedside instead of in a locked medication area. The resident, admitted with diagnoses including muscle wasting and atrophy, generalized muscle weakness, liver cell carcinoma, secondary malignant neoplasm of the nervous system, and type 2 DM, had an active treatment order dated 2/26/2026 to cleanse the scrotum with normal saline, pat dry, and apply Nystatin powder every shift for 14 days, documented on the Treatment Administration Record and Order Summary Report. The resident's MDS indicated intact cognitive skills but dependence or substantial/maximal assistance with toileting, bathing, dressing, footwear, and personal hygiene.

During observation at the bedside, surveyors saw a bottle of Nystatin powder with the pharmacy label on top of the bedside drawer, and both the resident and a family member stated the Nystatin was kept at the bedside and accessible to everyone. A subsequent observation of the treatment cart with the treatment nurse showed that the Nystatin powder ordered for this resident was not stored in the cart. The treatment nurse stated the Nystatin should have been stored in the treatment cart and that only licensed nurses should obtain and apply it. The DON stated that all ordered medications should be kept in a locked place with access limited to licensed nurses. Review of the facility’s “Storage of Medications” policy, revised April 2019, showed that all drugs and biologicals are to be stored in locked compartments, with nursing staff responsible for maintaining safe and secure medication storage areas, which was not followed in this instance.