Medication Security Lapse During Administration
Penalty
Summary
The facility failed to ensure the secure storage of medications during a medication administration pass for a resident. During an observation on December 11, 2024, a licensed practical nurse (Employee 10) administered medications to a resident who refused to take her Metoprolol medication due to concerns about excessively lowering her blood pressure. Employee 10 removed the Metoprolol tablet from the medication cup and placed it in an open plastic cup on top of the medication cart, stating she would dispose of it later at the nurses' station. Subsequently, Employee 10 left the medication cart unattended in the hallway while administering medications to another resident in the same room. During this time, the unsecured Metoprolol tablet remained on top of the cart, out of Employee 10's view, from 8:54 AM to 8:58 AM. Upon returning to the cart, Employee 10 confirmed that the tablet was left unsecured. The surveyor discussed these concerns with the Nursing Home Administrator and the Director of Nursing later that day.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No residents were harmed. 2. Employee 10 was immediately educated on proper storing of medications. 3. All licensed staff were educated on proper storing of medications. 4. A random audit of storing of medications will be conducted weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.