Medication Cart Security Breach
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an incident involving Medication Cart #1. On the morning of August 24, 2024, the medication cart was observed to be unattended and unlocked in the hallway outside a resident's room. Med-Aide A was inside the resident's room with her back to the door, unaware that the cart was unsecured. Surveyor B was able to open and close the drawers of the cart without Med-Aide A noticing until the second drawer was opened. This lapse in security could have allowed unauthorized access to medications. Interviews with Med-Aide A, LVN C, the Director of Nurses, and the Administrator revealed a misunderstanding and lack of adherence to the facility's policy regarding medication cart security. Med-Aide A believed it was acceptable to leave the cart unlocked if the drawers were facing the resident's room, despite having been in-serviced on the importance of locking the cart when not in use. Both LVN C and the Director of Nurses confirmed that the expectation was for medication carts to be locked unless a nurse or med-aide was actively administering medications. The Administrator reiterated this policy, emphasizing that there were no exceptions. A review of the facility's policy on medication use administration, last updated in May 2023, confirmed that medication carts must be locked when not in use or when not within the sight of licensed staff. Additionally, a record review of a nursing in-service from July 2024 showed that Med-Aide A had attended training that included instructions not to leave medication carts unlocked when unattended. Despite this training, the incident on August 24, 2024, demonstrated a failure to comply with these protocols, potentially compromising the safety of residents and others in the facility.
Penalty
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Surveyors found that discontinued narcotic medications for multiple residents, including those who had died or been discharged, remained in locked medication carts instead of being removed and stored or destroyed per policy. Observations of several medication carts revealed leftover Tramadol, oxycodone-acetaminophen, lorazepam, morphine sulfate (including unopened bottles), and Percocet still assigned to residents no longer in the facility. LPNs confirmed the residents were discharged or deceased and that the narcotics had not been removed, and the Interim DON acknowledged awareness that expired narcotics remained in the carts despite a policy requiring discontinued controlled substances to be removed from patient care areas and secured until destruction.
The facility did not follow its policy requiring daily temperature checks of medication refrigerators, with multiple days lacking documented temperatures across several nursing stations and an entire month of logs missing. The Administrator confirmed the missing entries, and the DON reported that prior month temperature logs could not be located. This failure in monitoring and documentation affected the storage conditions of medications for all residents whose drugs were kept in these refrigerators.
A resident with paraplegia, ventilator dependence, and a stage 4 pressure ulcer had ordered oral medications, including a blood thinner, iron, and fludrocortisone for blood pressure, left unattended in a medication cup on the bedside table while the resident was asleep and the nurse was at the nurse’s station. The unit manager confirmed the medications and that they were left in the room while the resident slept. Facility policy required medications to be administered as prescribed and to remain in the sight of the nurse until administration, but this was not followed.
Surveyors found multiple unsecured controlled substances, including lorazepam concentrate and morphine sulfate oral solution, lying on the DON’s desk instead of being stored in locked, permanently affixed compartments as required. These medications belonged to a current resident and several discharged residents and still contained varying amounts of narcotics. Facility policies required that controlled substances be kept in a securely locked area with restricted access and destroyed within a few days of discontinuation, but the DON acknowledged being behind on destruction. This failure affected several identified residents and had the potential to impact many independently mobile residents in the facility.
Surveyors found that RNs repeatedly left medication carts unlocked and unattended in hallways while administering medications to residents in their rooms. The carts, containing drugs and biologicals, were not secured despite being accessible in areas where cognitively impaired and independently mobile residents were present. In interviews immediately following these observations, the RNs acknowledged that they had not locked the carts, resulting in noncompliance with requirements for secure storage of medications.
Surveyors found that medication carts on two different floors were left unattended and unlocked near nurses’ stations on separate occasions, and LPNs on each floor confirmed the carts had been left in this condition. The facility’s written policy required all medications to be stored in locked compartments, but this was not followed, creating a situation in which medications on the first and second floors were not secured for the majority of residents, excluding those on a secured memory care unit.
Failure to Timely Remove and Dispose of Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to timely remove and properly dispose of discontinued narcotic medications, including those for residents who had died or been discharged. Surveyors reviewed records and medication carts and found multiple instances where controlled substances remained in the narcotic drawers after the medications had been discontinued or the residents were no longer in the facility. For one resident who had expired, 15 tablets of Tramadol 50 mg remained in the 100-hall medication cart. Another resident with end stage renal disease, congestive heart failure, and multiple malignancies had 22 tablets of discontinued Tramadol HCL 50 mg still stored in the 300-hall medication cart after discharge. Additional observations showed that a resident with anxiety, hemiplegia, hemiparesis, and adjustment disorder had 22 tablets of discontinued oxycodone-acetaminophen 10-325 mg remaining in the narcotic drawer. A resident with dementia, schizophrenia, atrial fibrillation, and congestive heart failure who had been transferred out still had 23 tablets of discontinued Tramadol 50 mg in the cart. Another resident with hip fracture, dementia, anxiety, bipolar disorder, and diabetes mellitus who had expired had 29 tablets of Tramadol 50 mg, 31 tablets of lorazepam 0.5 mg, and a full unopened bottle of liquid morphine sulfate remaining in the locked narcotic drawer. Surveyors also identified that a resident with thoracic vertebra fracture, quadriplegia, contracture, and left shoulder stiffness who had been discharged still had 20 oxycodone-acetaminophen 5-325 mg tablets in the narcotic drawer, and a resident with Alzheimer’s disease, dementia, chronic kidney disease, and peripheral vascular disease who had expired under hospice care had 28 lorazepam 0.5 mg tablets and an unopened bottle of morphine sulfate concentrate remaining in the cart. A resident with migraine, osteoarthritis, heart disease, and Parkinsonism who had discharged to another LTC facility still had 22 Percocet 10-325 mg tablets in the narcotic drawer, despite active orders having been discontinued or the resident no longer being present. LPNs confirmed that these residents were no longer in the facility and that their narcotics remained in the medication carts, and the Interim DON acknowledged awareness that expired narcotics remained in the carts. Facility policy stated that discontinued controlled substances were to be removed from patient care areas and temporarily stored in a securely locked area until destruction, which was not followed in these cases.
Failure to Perform and Document Daily Medication Refrigerator Temperature Checks
Penalty
Summary
The facility failed to ensure medication refrigerators were monitored and maintained according to its policy requiring daily temperature checks for all medication storage refrigerators. Review of the Station #1 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperatures on 03/05/26, 03/13/26, and 03/19/26. Review of the Station #2 Unit Temp Log Check form for the same period showed no documented refrigerator temperatures on 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/12/26, and 03/13/26. Review of the Station #4 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperature on 03/17/26. The Administrator confirmed these missing temperature checks during an interview, and the DON confirmed that the refrigerator temperature logs for 02/01/26 to 02/28/26 were missing and could not be located. The undated Medication Refrigerator Temperature Check Policy stated that all medication refrigerators were to be checked daily to ensure they remained within the proper temperature range. This deficiency had the potential to affect all 78 residents in the facility and was investigated under Complaint Number 2786595. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency related broadly to the management and monitoring of medication refrigerator temperatures for all residents whose medications were stored in these units.
Unattended Oral Medications Left at Bedside Contrary to Facility Policy
Penalty
Summary
Facility staff failed to ensure medications were administered as ordered and properly stored until administration for one resident. The resident had paraplegia, was ventilator dependent, and had a stage four pressure ulcer, with an admission date of 05/14/25. A quarterly MDS indicated the resident had intact cognitive function and required set up for eating, and the care plan documented a need for assistance with activities of daily living due to weakness, with an intervention to administer medications as ordered. Physician orders included Xarelto 10 mg by mouth in the morning, Ferrous Sulfate 325 mg by mouth once daily, and Fludrocortisone Acetate 0.1 mg, two tablets by mouth daily for blood pressure. On 03/17/26 at 8:13 A.M., surveyors observed a small medication cup containing four medications left on the resident’s bedside table while the resident was in bed sleeping with a sheet over his head, and the nurse was down the hall at the nurse’s station. The unit manager confirmed that the medications in the cup were Xarelto, Ferrous Sulfate, and Fludrocortisone Acetate and verified that the medications had been left unattended in the room while the resident was sleeping. Review of the facility’s “Administering Medications” policy, revised April 2019, showed that medications were to be administered in a safe and timely manner as prescribed, with medication administration times determined by resident need and benefit, and that during administration medications were to be kept in the sight of the nurse until given to the resident. The observed practice of leaving medications unattended in the resident’s room was inconsistent with this policy.
Unsecured and Undestroyed Controlled Substances Left on DON’s Desk
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of controlled substances when multiple unsecured narcotic medications were observed lying on the DON’s desk during an interview with the DON and the Regional Clinical Director. The medications included lorazepam oral concentrate and morphine sulfate oral solution prescribed for one resident who still resided in the facility, with significant amounts remaining in the bottles, as well as multiple bottles of morphine sulfate and lorazepam concentrate for several residents who had been discharged. The DON confirmed that these controlled medications were unsecured and acknowledged that controlled substances should be stored in a permanently affixed, locked compartment. The facility’s written policies titled “Controlled Substances” and “Discarding and Destroying Medications” required that controlled substances be separately locked in permanently affixed compartments and that any remaining controlled substances after discharge or discontinuation be securely locked in an area with restricted access until destruction, with disposal to occur immediately and no longer than three days after discontinuation. Contrary to these policies, the controlled medications for discharged residents were kept on the DON’s desk rather than in a securely locked area, and the DON stated she was behind in destroying the controlled substances. This failure to secure and timely destroy controlled substances affected four identified residents and had the potential to affect 56 independently mobile residents in a facility census of 70.
Unattended Unlocked Medication Carts During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked when unattended, as required for the secure storage of drugs and biologicals. Surveyors observed multiple instances on the same day where Registered Nurse (RN) #201 and RN #200 prepared medications at unlocked medication carts positioned in the hallway outside residents’ rooms and then entered the rooms without securing the carts. These observations occurred during medication administration for several residents, including Resident #85 and Resident #77 for RN #201, and Residents #21, #88, #84, and #52 for RN #200. During interviews conducted shortly after each observation, both RN #201 and RN #200 confirmed that they had not locked the medication carts before leaving them unattended. The report notes that this failure had the potential to affect nine cognitively impaired and independently mobile residents on the 200 and 300 halls, identified during the survey as Residents #17, #34, #40, #50, #57, #59, #63, #87, and #93. The cited deficiency is specifically related to the requirement that all drugs and biologicals be stored in locked compartments, with separately locked compartments for controlled drugs.
Unattended and Unlocked Medication Carts on Multiple Floors
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments as required by facility policy and professional standards. During a complaint investigation, surveyors observed an unattended and unlocked medication cart next to the first-floor nurses’ station on 03/10/26 at 10:30 A.M., and the LPN present at that time confirmed the cart had been left unattended and unlocked. On the following day, 03/11/26 at 12:00 P.M., surveyors again observed an unattended and unlocked medication cart next to the second-floor nurses’ station, and the LPN on duty confirmed that this cart was also unattended and unlocked. The facility’s written policy, “Medication Labeling and Storage” dated February 2023, stated that all medications would be stored in locked compartments. This deficiency had the potential to affect all residents on the first and second floors, excluding 13 residents identified as residing on the secured memory care unit. These observations and staff confirmations demonstrated that the facility did not follow its own policy or accepted professional principles for secure medication storage, resulting in medication carts being left unlocked and unattended on two separate floors during the survey period.
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