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Based on observation, interview, record review, and policy review, it was determined the facility failed to assess the capacity of Patient C to self-administer medication (Dulera is an inhaler used to control symptoms of asthma), failed to visually evaluate the medication, and failed to address the security of the medication. Observation revealed a Dulera inhaler was being stored on the patient's bedside table. The inhaler was not labeled with the patient's name or prescribing information and the medication expired on 08/08/18,

The findings include:

Review of a facility policy titled "Medication Management/Patients Personal Medication," revealed if a patient's personal drugs must be retained in the facility, they would be packaged, sealed, labeled with the patient's name, and stored. The policy further stated personal drugs would be stored with other drugs supplied by the facility, unless directed otherwise by the practitioner.

Review of a facility policy titled "Medication Administration," effective April 2015, revealed nursing staff must assess the patient or designated family member regarding their competency for self-administration of medication. The policy stated the training and information was required to be documented.

Observation during a tour of the facility on 09/25/18 between the hours of 11:45 AM and 12:45 PM revealed a Dulera inhaler was stored on the bedside table of patient room 9 (Patient C). Further observation revealed the Dulera inhaler expired on 08/08/18 and was not labeled with a patient name or instructions for use.

Medical record review revealed the facility admitted Patient C on 08/28/18 at 10:15 PM with diagnoses that included right thigh abscess and cellulitis with Methicillin Resistant Staph Aureus (MRSA), Acute Kidney Injury superimposed on chronic kidney disease, Urinary Tract Infection, and Paroxysmal Atrial Fibrillation.

Review of Patient C's physician orders revealed an order dated 08/29/18 for the patient to use a Dulera Inhaler from home. However, there was no documented evidence that the patient had been assessed to be able to self-administer the medication.

Interview with the Pharmacist on 09/25/18 at 4:20 PM, revealed he had no knowledge that medications were being stored in patient rooms and stated medications should not be left in the patient's room. According to the Pharmacist, all home medications should be assessed by Pharmacy prior to allowing the patient to use the home medication.

Interview with the Charge Nurse on 09/25/18 at 6:00 PM, revealed she had no knowledge of any home medication that had been ordered. The Charge Nurse stated that medications were left at the bedside on occasion for the convenience of staff and patients. The Charge Nurse gave no explanation why education had not been provided regarding the medication left in Patient C's room.

Based on observation, interview, and policy review, it was determined the facility failed to ensure drugs and biologicals were kept in a secure area. Observation on 09/25/18 revealed drugs and wound care supplies were being stored in patient rooms.

The findings include:

Interview with the Pharmacist on 09/25/18 at 4:20 PM revealed medications should not be left in patients' rooms.

Observation during a tour of the facility on 09/25/18 from 11:45 AM to 12:45 PM revealed the following medications/wound care supplies were stored in patient rooms:

1. Observation in patient room 11 revealed a patient occupied Bed B. Observation of Bed A revealed the bed was not occupied and the following were being stored on the bed: a suture removal tray with scissors/tweezers, four (4) Povidone-Iodine Antiseptic Swab sticks; one (1) four-ounce bottle of PVP Prep Solution (wound cleanser that contains Iodine); one (1) tube of Providine First Aid Ointment; and one (1) twelve-ounce bottle of SAF-Clens Advance Formula (wound cleanser).

2. Observation in patient room 10 revealed the following medications were being stored on the patient's bedside table: Fluticasone Propionate Nasal Spray; three (3) packs of Mepitel bandages, and two (2) one-pint bottles of Chlorhexidine Gluconate 0.12% medicated oral mouth rinse.

3. Observation of patient room 9 revealed Fluticasone Propionate Nasal Spray and Nyamyc (anti-fungal medication) were being stored on the patient's bedside table.

4. Observation of patient room 6 revealed the following medications were being stored on the windowsill: two (2) four-ounce bottles of PVP Prep Solution (wound cleanser that contains Iodine), one suture removal tray, and a 473-milliliter bottle of HYSEPT 50 (wound cleanser that contained 0.50% Sodium Hypochlorite Solution) for topical use only.

5. Observation in patient room 5 revealed two (2) bottles of Hydrogen Peroxide were on the patient's bedside table.

6. Observation in patient room 2 revealed two (2) tubes of Santyl Ointment (applied to wounds to remove dead tissue), one (1) bottle of PVP Prep Solution, one bottle of Nyamyc, and one (1) bottle of Fluticasone Propionate Nasal spray were being stored in the patient's room.

Interview with the Charge Nurse on 09/25/18 at 6:00 PM revealed medications were left at the patient's bedside on occasion for the convenience of staff and patients.

Interview with the Licensed Practical Nurse (LPN) on 09/25/18 at 3:20 PM revealed unused supplies often accumulated in patient rooms.

Interview with Registered Nurse (RN) #1 on 09/25/18 at 3:20 PM revealed children often visited patient rooms and medications/biologicals left in the rooms were unsecured and accessible to visitors.