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F0761
D

Improper Storage of Controlled Drugs in Medication Room

Hatboro, Pennsylvania Survey Completed on 12-12-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that controlled drugs subject to abuse were stored and labeled in accordance with professional standards in the B wing medication room. During an observation, it was found that the door to the medication room had a coded lock, but the code was written on the door jamb, making it easily accessible. This was confirmed by the unit manager, Employee E8, during an interview at the time of the observation. Additionally, the medication refrigerator inside the B wing medication room was not locked, and it contained a transparent plastic box with an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside. The plastic box was not permanently affixed to the refrigerator, which was also confirmed by Employee E8 during the observation. These findings indicate a failure to adhere to the facility's policy on the safe, secure, and proper storage of medications and biologicals.

Plan Of Correction

Education provided to all licensed nurses regarding policy #4.2 the Storage of Controlled Substances. Nurse Managers will conduct audits on all units of the facility medication rooms to ensure that the narcotic box located in each medication refrigerator remains secured and locked as per above policy. The audits will be conducted daily times 4 weeks, then bi-weekly times two months, then monthly times 3 months. Door codes have been removed from door jams and included in above audit to ensure compliance.

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