Brunswick Health & Rehab: Unsupervised Drug Access - NC

Resident #7 had four opened tubes of lidocaine-prilocaine cream and an opened bottle of naproxen sodium sitting on his overbed tray table when inspectors arrived at Brunswick Health & Rehab Center on April 7. The medications were visible to anyone entering the room on a unit where confused residents sometimes wander into other patients' rooms.

The resident had been admitted with end-stage renal disease requiring dialysis, gastrointestinal hemorrhage, and anemia. His medical records showed no physician orders for either medication he was keeping at his bedside.

"I had naproxen in my room in case I had a headache and I took the medication on occasion," the resident told inspectors. He said he applied the lidocaine cream to his fistula before dialysis treatments. His family had brought both medications from an outside pharmacy.

The medication aide assigned to his care that morning stood at her cart outside his room, unable to see what the resident was doing. She told inspectors she had no idea he had medications in his room.

"I was unaware that Resident #7 had medications in his room including the tubes of lidocaine cream and a bottle of naproxen observed on the overbed tray table," Medication Aide #1 said.

Federal regulations require nursing homes to assess whether residents can safely self-administer medications before allowing the practice. The facility had completed no such assessment for Resident #7, despite his quarterly evaluation showing he was cognitively intact with no behavioral issues.

His physician explained the dangers during an interview with inspectors. Naproxen is a nonsteroidal anti-inflammatory drug that the resident should not self-administer, and unsupervised use could lead to complications. The prescription lidocaine cream is an anesthetic that could also cause complications without proper supervision.

"Residents were to be assessed for the ability to safely self-administer medications," the physician told inspectors.

The resident's care plan contained no provisions for self-administering medications. His medical record contained no assessments for medication self-administration. His physician orders included no authorization for him to manage his own drugs.

Unit Manager #1 confirmed that medications should never be kept at the bedside without proper protocols. She explained the required process: residents must be assessed for their ability to self-administer medications, the medications must be secured, a physician's order must be obtained, and the care plan must be updated.

"There were confused residents on the unit who sometimes entered other residents' rooms," she told inspectors, explaining why unsecured medications posed additional risks.

The unit manager said she was unaware the resident was self-administering naproxen and lidocaine cream or that the medications were kept unsecured in his room.

Director of Nursing confirmed she also had no knowledge of the situation. She outlined the proper procedure for medication self-administration: safety assessment, physician order specifying which medications could be self-administered, proper storage, and updated care plan.

"I was not aware that Resident #7 had medications in his room that he was self-administering," she said.

The facility's failure created multiple safety risks. The resident was taking a potentially dangerous anti-inflammatory drug without medical supervision, despite his history of gastrointestinal hemorrhage. He was applying prescription anesthetic cream without oversight. Both medications sat openly accessible to confused residents who might wander into his room.

The naproxen posed particular concerns given the resident's medical history. NSAIDs can worsen gastrointestinal bleeding and affect kidney function, both significant risks for someone with his diagnoses.

The lidocaine-prilocaine cream, while commonly used before dialysis procedures, requires proper application and timing to be effective and safe. Unsupervised use could lead to inadequate pain control or adverse reactions.

Brunswick Health & Rehab Center's medication management system had completely failed this resident. Staff assigned to oversee his medications didn't know what drugs he had. Managers responsible for ensuring proper protocols weren't aware of his self-medication. The nursing director charged with medication safety had no knowledge of the situation.

The resident had been managing his own medications for an unknown period while facility staff remained oblivious. His quarterly assessment showed cognitive ability to potentially handle some self-administration, but the facility never evaluated whether he could safely manage these specific medications or any medications at all.

Federal inspectors found the facility failed to determine whether self-administration was clinically appropriate for the resident. The violation received a minimal harm rating, but the potential consequences were far more serious.

The resident continued dialysis treatments three times per week, applying lidocaine cream to his fistula site without medical oversight. He kept taking naproxen for headaches without physician monitoring, despite his bleeding history and kidney disease.

His family brought the medications from an outside pharmacy, apparently unaware that nursing home residents cannot simply keep prescription drugs in their rooms without proper authorization and safety protocols.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Brunswick Health & Rehab Center from 2026-04-09 including all violations, facility responses, and corrective action plans.

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