Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to adhere to proper storage protocols for medications and biologicals, as evidenced by several observations and staff interviews. During a tour, a medication cart on unit 3A was found unattended and unlocked, which was confirmed by an LPN. Additionally, during a medication pass, a liquid medication was observed sitting in a cup on top of the same medication cart, waiting to be administered to a resident who was still eating. This was confirmed by another LPN, who acknowledged that the pre-poured medication was not yet given to the resident. Further deficiencies were noted in the medication room labeled [ROOM NUMBER]BC, where a secured narcotic lock box inside the refrigerator was found unlocked, containing two oral concentrated Ativan doses. This was confirmed by an LPN, indicating a failure to secure controlled substances properly. These findings highlight lapses in the facility's adherence to its own Medication Storage policy, which mandates that all drugs and biologicals be stored in locked compartments and under direct observation during medication passes.
Plan Of Correction
Medication cart on 3A was immediately locked. Liquid medication on 3A was removed. Lock box on 2BC was locked and replaced. Education on locking carts, the process of passing medications, and locking narcotic boxes will be provided to nurses by the DON or designee on or before 2/11/2025. Audits will be conducted on locking carts, the process of passing medications, and locking narcotic boxes weekly on 2 nurses/med passes x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.