Medication Cart Security Deficiency
Penalty
Summary
The facility failed to store medications securely in one of its medication carts, specifically the 3-West Low hall medication cart. According to the facility's "Medication administration general guidelines" policy, all medications must be kept secured and in a locked environment. However, during observations on February 3, 2025, at 12:13 p.m., the 3-West unit's low hall medication cart was found unlocked, with no registered nurse, licensed practical nurse, or any other staff member present to secure the cart. Further observations at 12:17 p.m. on the same day confirmed that the 3-West low hall medication cart #1 remained unlocked, again with no staff present to secure it. During an interview at 12:18 p.m., the Assistant Director of Nursing (ADON) confirmed the facility's failure to store medications securely in one out of six medication carts as required by regulations. This deficiency was noted under the relevant state codes for pharmacy and nursing services.
Plan Of Correction
- Immediate termination of agency RN assigned to the med cart on 3 West Low Hall during complaint survey. - Immediate education to all licensed nursing staff regarding Policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use. - DON/ADON/Designee will continue education on policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use to all licensed staff. - Audits of the meds cart are being completed 2x per shift x 10 days, 3x per week for 2 weeks and weekly x4. - All results will be reported to the QAPI Committee for review.