The aide also left a 4-ounce bottle of antiseptic skin cleanser on top of the resident's refrigerator during the October morning incident at Ft Worth Southwest Nursing Center on Alta Mesa Boulevard.
Federal inspectors found the violations during a complaint investigation. The resident told inspectors that staff must have left the items in his room that morning, adding that staff normally kept all his medications secured.
Aide B admitted she used the zinc oxide while changing the resident but was rushing to answer another call light. "She was rushing and must have left the ointment in his room," according to the inspection report. The aide acknowledged she wasn't supposed to leave ointment in the resident's room but forgot while hurrying.
"The risk was Resident #1 could have got it or touched it," the aide told inspectors.
Nobody knew where the antiseptic cleanser came from. RN A, who supervised medication administration, said she didn't put any antiseptic on the resident that morning and wasn't sure if it came from the resident's home or the facility. The aide said she didn't have the antiseptic and wasn't sure who was responsible for it.
The registered nurse confirmed that prescription creams and antiseptic would be administered by a nurse, while aides were responsible for applying basic creams and ointments. She stated those items should not be left where residents could access them.
Federal regulations require all drugs and biologicals to be stored in locked compartments, with only authorized personnel having access. The facility's own undated policy on medication administration states: "Medications will not be left at the bedside."
The Director of Nursing acknowledged the violations when confronted by inspectors. He said the facility had started an in-service to remind staff not to leave medications, ointments, and cleansers in residents' rooms.
Both the Director of Nursing and the Administrator recognized the potential consequences. The Director of Nursing said there was potential for harm, like the resident ingesting something. The Administrator stated the risk was possible sickness.
The inspection occurred as part of a complaint investigation on November 26, 2025. Inspectors reviewed five resident rooms for pharmacy services and found violations in one room.
This type of medication storage failure represents what federal regulators call "minimal harm or potential for actual harm" affecting few residents. However, the violation could place residents at risk of accessing unauthorized medications and lead to possible harm or drug diversion.
The facility policy requires practice standards for safe administration of medications, but the morning rush to respond to call lights created exactly the scenario the rules were designed to prevent. The aide's admission that she forgot the rule while hurrying highlights how staffing pressures can compromise basic safety protocols.
The uncapped ointment tube posed particular concern since it was easily accessible and the resident could have touched or ingested the contents. Zinc oxide, while generally safe for external use, can cause stomach upset or more serious complications if swallowed.
The antiseptic skin cleanser presented additional risks, as these products often contain alcohol or other chemicals that could cause harm if accessed by residents with cognitive impairment or confusion.
Federal inspectors noted this was one of five resident rooms they reviewed for pharmacy services, suggesting they were conducting a targeted investigation of medication storage practices rather than a routine survey.
The facility's response of implementing additional in-service training indicates management recognized the seriousness of leaving medications accessible to residents. However, the incident reveals gaps between written policies and actual practice during busy shifts.
The violation occurred despite clear federal requirements and the facility's own written policies prohibiting bedside medication storage. Staff acknowledged knowing the rules but failing to follow them under time pressure.
The resident's statement that staff "must have left those items" suggests this may not have been an isolated incident, though inspectors found violations in only one of the five rooms they examined.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ft Worth Southwest Nursing Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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