Unsecured Medication Storage in Nurse's Station
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed during a survey on Unit 2 East. Specifically, 16 medications for seven residents were found unattended and unsecured on a shelf in the nurse's station, which lacked a door or means to lock the area. The medications included Chlorhexidine mouth rinse, Lactulose, Sorbitol, Ipratropium Bromide and Albuterol Sulfate inhalation, Citrucel Powder, Lanta liquid, Refresh tears, and Betadine solution. These medications were accessible to residents, as the nurse's station was located near a common area where residents were present, and there was no staff within visual view to monitor the area. Interviews with various nursing staff revealed a lack of awareness and adherence to the facility's medication storage policy. Licensed Practical Nurse #2 acknowledged the medications should not have been stored on the shelf and were unsure how long they had been there. Unit Manager Licensed Practical Nurse #4 and Licensed Practical Nurse #5 were unaware that overflow medications could not be stored on the shelf, and both confirmed that the nurse's station was not a secure location. Licensed Practical Nurse #3 noticed the medications but did not take action to secure them or inform the Nursing Supervisor. The Director of Nursing and the Pharmacy Consultant both confirmed that medications should be stored in a locked, secure area, and the nurse's station shelf was not appropriate for medication storage. The Pharmacy Consultant noted that storing medications on the shelf could potentially allow resident access, posing a safety issue. The facility's process for receiving medications involved the Nursing Supervisor delivering them to the appropriate unit, expecting staff nurses to secure them in a medication cart or locked cabinet, which was not followed in this instance.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F761- Label/store Drugs and Biologicals** 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident number 94 the eye drops were removed and ordered directly through pharmacy with patient label. b. For Resident number 267 the [MEDICATION NAME] was discarded. c. For Residents 17, 22, 68, 70, 72 immediately removed the medications from the unsecure shelf and placed all their medications in their locked med cabinet and or med cart. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. a. All residents who receive medication and or biologicals have the potential to be affected by this deficient practice. b. On (MONTH) 9, 2025 the DON, ADON and Manager of the unit did a complete med audit. This included all shelves in the center of the unit near common areas where residents sit and no medications were found. An audit was also completed on all medication orders as they relate to supplies on hand. (01) 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur. a. Three (3) cabinets on 2 east were identified to use for stock meds and overflow meds. Maintenance installed locks and all stock and overflow medications are now in the 3 locked cabinets located in the common area above the sink off the nurse’s station. The cabinets are located high on a wall that is in the common area to residents and staff and open to the nurse’s station; the cabinets will remain locked at all times. They are against the wall above the sink. The cabinets are sufficient to hold any overflow medications which do not fit in the locked medication cart and also for stock meds. No narcotics are stored in this area. The narcotics are kept in a double locked cabinet in the nurses stations. There is no overflow area necessary for narcotics. Nursing staff will unlock and obtain overflow medication/biologicals or stock meds as needed per specific orders for patients, lock the cabinet and bring the medication/biological directly to the respective medication cart to be administered and secured and stored. All RN’s, LPN’s will be in serviced by our ADON or nurse managers on all aspects of medication administration & storage, including proper receiving of medications and biologicals from pharmacy and the immediate delivery of the medications and biologicals to the appropriate secured storage area. All RN’s and LPN’s will have the P&P reviewed regarding Medication Cart audits, Medication room audits or medication cabinet audit, medication administration & documentation, storage of medication, and ordering and receiving medications from the dispensing pharmacy. (02) 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur a. Our nurse manager or designee will be completing weekly audits in the common area and nurse’s station to ensure no medications are in an unlocked area. The manager will also conduct weekly medication cart and storage cabinet audits to ensure there are no discontinued medications. Medication administration audits will also be conducted yearly with each RN and LPN’s evaluations to ensure adherence to policy & procedure. (03) b. The nurse manager and or designee is responsible for conducting medication cart audits, medication room audits, medication storage audits, and audits of any medication storage cabinet and refrigerator storage of medications weekly on all Nursing units within TMR. Any negative findings will be addressed and corrected immediately. The results of these audits are given to quality and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. (04) c. Any negative findings will be addressed and corrected immediately. The results of these audits will be reported by the DON at our Quarterly Quality and Resident Safety Committee for review. d. The pharmacy consultant agreed with the decision for the new location for stock and overflow meds and the security of medications. The pharmacy consultant will audit med storage areas every 2 weeks until we achieve 100% compliance for 8 consecutive audits. Thereafter, the pharmacy consultant will conduct spot audits and a full audit of med carts and med storage yearly throughout the building. (05) e. The Audits done by the nurse manager and or designee will be done weekly until we achieve 100% compliance over 8 consecutive weeks, after which, the findings will be reviewed by the Quality Assurance Committee for compliance. The Quality Committee will provide us with a schedule to follow for future medication cart and storage cabinet audits throughout the year. Medication administration audits will continue to be conducted yearly with each RN and LPN’s evaluations. The results of these audits will be given to the Quality Department and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. f. While the primary responsibility for audits will be the unit manager, weekly audits may be done by a designee. The designee may include the DON, ADON, the Quality Team, other unit manager and or supervisor. The manager of each unit will be responsible for the delegation each week depending on staff schedules. 5. The date of the correction and the title of the person responsible for the correction of the deficiency. Date of Correction: (MONTH) 5, 2025 Person Responsible: Director of Nursing