Expired supplements were found in the medication room refrigerator, and an antifungal ointment was repeatedly observed unsecured on a resident’s bedside table without an order or self-administration authorization. In another observation, an LPN left a medication cup unattended in a resident’s room during med pass before the resident was observed taking the meds. Staff interviews and facility policy confirmed that medications are to be centrally stored and that residents may self-administer only when assessed and ordered to do so.
An unsecured medication cart was observed unattended in the hallway near the nurses' station with no nursing staff present. Multiple staff members, two residents, and a CNA passed by before an LPN found the cart unlocked and secured it. The DON, the assigned LPN, and the Administrator confirmed facility policy required medication carts to remain locked whenever unattended or not in use.
A resident with dementia, chronic pain, and other significant diagnoses had OTC topicals and cough drops left in plain view at the bedside without orders for self-administration or evidence of assessment/care planning for self-administration. Observation found antifungal powder, Hibacleanse, Muscle Rub, and cough drops on the nightstand, and both an LPN and the DON stated these items were medications that should not be kept at bedside without proper authorization and secure storage.
Medications and topical treatments were found unsecured in residents’ rooms instead of being kept in locked storage or handled by nursing staff. One resident with diabetes, venous insufficiency, and ESRD had wound ointment on the windowsill, while another cognitively intact resident with pain and quadriplegia had Icy Hot on the bedside table and reported self-using it. Staff, including an LPN, wound care nurse, CNA, and DON, stated these products should not be left in resident rooms and should be stored by nursing staff.
Medications were left unsecured in resident rooms for multiple residents without orders, assessments, or care plans authorizing self-administration. An LPN, CMA, and DON all confirmed that topicals and oral meds such as Nystatin, antifungal powder, Tums, and other tablets should not be left at bedside unless the resident had been evaluated and approved to self-administer, and the record showed no such authorization for the affected residents.
An LPN left medication cart P2 unlocked and unattended in a hallway, and the cart’s lock would not engage when she tried to secure it. The LPN said she had difficulty with the lock since the start of her shift but did not report it, and there was no shift-change communication about the issue. The DON later confirmed the cart remained unlocked when the key turned, and the Administrator stated he was aware the lock was not working.
Medication Left at Bedside Without Authorization A resident with intact cognition and occasional pain had a tube of diclofenac gel found on the bedside table while the resident was out of the room. There were no physician orders, care plan entries, IDT notes, or EHR assessments authorizing or assessing self-administration. The Activities Director removed the medication, and the DON confirmed there was no evidence the resident was approved to self-administer medications.
Expired and unlabeled medications were found in medication carts and medication rooms, along with loose pills that were not identifiable. An RN Unit Manager and an LPN observed loose tablets in carts, and multiple expired items were identified, including Sodium Chloride syringes, Chlorhex Gluconate solution, Milk of Magnesia, Pramoxine Hydrochloride, and Biofreeze Gel. An open bottle of Fish Oil was also found in the refrigerator without an open date. The DON stated that expired medications should be removed from stock and opened medications should be labeled with an open date.
A resident with seizures and multiple cardiovascular and neurologic diagnoses had a discontinued Ativan order on record, yet an expired Lorazepam vial was found in the medication refrigerator inside the controlled meds lock box. Staff and the DON stated expired meds should not remain in storage, but the DON also said there was no routine cadence for disposal; facility policy required outdated and discontinued meds to be removed and destroyed per procedure.
A resident with intact cognition and diagnoses including dysphagia, GERD, HTN, and anxiety had a Soursop supplement left on the bedside table even though there was no documented IDT assessment or self-administration approval. The resident said he ordered and took the supplement himself, while an LPN later confirmed it was not supposed to be unattended at the bedside and found no order in the chart; a later provider order specified clinician-only administration.
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