Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to properly store medications, as evidenced by the presence of loose tablets and capsules in the medication carts for the 300 hall rooms. During an observation, surveyors found four loose tablets and one loose capsule in one medication cart, and ten and a half loose tablets in another cart. These medications were unsecured and not properly accounted for, increasing the potential for drug diversion. Licensed Practical Nurses (LPNs) 5 and 7 were responsible for destroying the unsecured medications using the drug buster solution, but they were unable to determine the ownership of the medications. Interviews with LPN5, LPN7, and the Director of Nurses (DON) revealed that it was the responsibility of all nurses to ensure medication carts were clean and that any loose pills should be disposed of in the drug buster solution. The facility's policy on the disposal and destruction of medication indicated that non-controlled medications, which are expired, refused, or adulterated, should be destroyed by nurses without the need for a second nurse. The policy also outlined the procedure for disposing of unused medications during medication pass. However, the presence of loose medications in the carts indicated a failure to adhere to these procedures.
Plan Of Correction
No residents were affected by this deficient practice. All loose medication were disposed of properly. LPN5 and LPN7 were unable to determine who the medications belonged. Both nurses were inserviced on proper handling of medication cards and the responsibility of keeping their medication carts clean and free of loose medications. All residents with medication orders are potentially affected. Director of Nursing or designee inserviced all nurses on the responsibility of maintaining cleanliness of the medication cart and proper disposal of medication. Inservice will be completed upon hire and annually thereafter. All nurses are to check assigned medication cart on their shift. The unit manager or designee will check med carts once per week to assure compliance with proper medication storage. Unit Managers will check med carts once per week to assure compliance with proper medication storage. The findings of these audits will be reported to the Director of Nursing on a monthly basis. All monthly audits will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.