Unsecured Morphine Leads to Resident Overdose
Summary
The facility failed to store a Schedule II Controlled medication, Morphine Sulfate, in a locked location, leaving it on top of a medication cart in plain view and unsupervised on a dementia care unit. This oversight allowed a resident, who had a history of wandering and drinking from unattended containers, to access the medication. The resident was found with the bottle of Morphine up to their lips, and upon retrieval, the bottle was empty. This incident led to the resident becoming unresponsive with a decreased respiration rate, necessitating the administration of Narcan and emergency transport to the hospital. The resident involved had a medical history that included dementia with psychotic disturbance, major depressive disorder, and other conduct disorders. The resident was known to wander the facility and had previously ingested non-food substances, such as fingernail polish remover, which required emergency intervention. On the day of the incident, the resident was observed wandering near the nurses' station where the medication cart was located, and later found with the Morphine bottle. The incident occurred when a Licensed Practical Nurse inadvertently left the Morphine bottle on the medication cart after administering a dose to another resident. The nurse placed the bottle in a biohazard bag on top of the cart and left the unit. The resident accessed the bottle during this time, leading to the overdose. The facility's investigation confirmed that the Morphine was not spilled, as no evidence of the liquid was found on the resident or in the surrounding area, indicating that the resident ingested the entire contents of the bottle.
Removal Plan
- R1 was evaluated and sent to the Local emergency room for evaluation. When EMS personnel arrived, they attempted to administer Narcan to R1 prior to transferring R1 to the local emergency room.
- V4, Licensed Practical Nurse, was suspended pending a comprehensive investigation of the incident.
- Upon Return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with hourly vital signs/Level of Consciousness for eight hours and then every shift times two days.
- Upon Return to facility, R1 had a change in condition. V6, Registered Nurse, administered Narcan to R1, called 911, and sent R1 back to the Local emergency room for Evaluation.
- R1 returned from the hospital. Upon return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with every 4 hour vital signs for 2 days.
- All licensed nursing staff were educated on Storage of Controlled Substances, Medication Administration, Accidents and Incidents, and Change of Condition Policies prior to their next scheduled shift either in person or via phone by V31 (former Director of Nursing), V2 (former Nurse and current Director of Nursing), (former Registered Nurse and current Director of Nursing), and V36 (Licensed Practical Nurse).
- V2 (former Registered Nurse and current Director of Nursing) contacted V37 (R1's Power of Attorney) for notification.
- V2 (former Registered Nurse and current Director of Nursing) contacted V12 (R1's Physician) for notification, V31 (former Director of Nursing), and the facility pharmacy provider for assistance with Medication Audits.
- V30 (Maintenance Director) completed a sweep of the Dementia Unit to ensure that all items that are liquid and hazardous products were locked up or put away out of reach.
- The Facility Corporate team (V32 Chief Nursing Officer, V33 Regional Clinical Consultant, V34 Chief Executive Officer, V35 Regional Director of Operations) reviewed and revised policies and procedures related to Medication Administration, Medication Storage, Accidents and Incidents, and Change of Condition.
- The Director of Nursing or designee will complete audits three times weekly for a period of 8 weeks in the following categories: Medication Administration Policy, Storage of controlled substances, Accidents and Incidents, and Change of Condition. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors identified multiple failures in medication labeling, dating, and storage, including an illegible lorazepam label in the refrigerator, an opened tuberculin vial and a Hepatitis B vaccine syringe improperly stored, and a non–permanently affixed locked box containing insulin and narcotics in the medication refrigerator. In a medication cart, loose unlabeled pills and various identified tablets were found in drawers, and a bottle of glucose test strips in use lacked an open date despite manufacturer instructions. An unattended medication cart was also observed with a pill on the floor nearby, which an LPN later admitted she had dropped and not properly located and destroyed.
Surveyors found expired acetaminophen 650 mg suppository floor stock on the North Hall medication cart, despite facility policy requiring proper labeling, storage, and removal of expired drugs. A CMA and an administrative nurse each confirmed that medication aides or nurses were responsible for checking the cart and discarding expired medications, but the expired suppositories remained available on the cart.
Surveyors identified that the facility failed to remove multiple expired medications and medical supplies from a medication room, including blood collection tubes, culture bottles, topical agents, dressings, and needle sets, despite a policy requiring immediate removal of outdated items. On another unit, a treatment cart containing peroxide, rubbing alcohol, resident-specific ammonium lactate 12% lotion, triamcinolone acetonide cream, and various dressings was left unsecured in a supply room with the door propped open. An LPN and an RNAC confirmed the expired items and the expectation that the cart and room should be secured, and the NHA acknowledged these failures.
Surveyors observed that a resident’s Novolog insulin pen on a medication cart was in use without an open or discard date, and a treatment cart contained four expired stock medications (aspirin, vitamin D, calcium with vitamin D, and zinc). A CMA verified the medications were expired, and an LN acknowledged that staff were required to date insulin pens when opened. These findings showed that staff did not consistently label insulin pens or remove expired stock medications as required by the facility’s medication storage policy.
Surveyors found multiple medication and treatment carts unlocked and unattended in hallways, despite containing enteral meds, PRN creams, insulin pens, scheduled meds, and OTC meds. On different units, carts were observed left without staff present while holding resident-specific and general treatment supplies. In interviews, an LN and an administrative nurse acknowledged that carts are required to be locked when out of view or not in use, and facility policy specified that medications must be stored in accordance with state and federal requirements.
Surveyors found multiple treatment carts unlocked and unattended in hallways, with nursing staff confirming that the carts had been left unsecured. An East Hall medication cart contained opened but undated ipratropium bromide, albuterol, and fluticasone. In addition, two residents had treatment products, including Vashe wound cleanser, zinc oxide, and triamcinolone cream, left on their bedside stands rather than stored in locked compartments. These findings show that medications and treatment supplies were not consistently secured or labeled according to required standards.
Improper Medication Labeling, Dating, and Storage in Medication Room and Cart
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly labeled, dated, and stored in accordance with facility policy and professional standards in both the medication room and a medication cart. In the medication room, surveyors observed a bottle of liquid lorazepam in the refrigerator with an illegible label on both the bottle and box, and the LPN present was unsure whether it should be refrigerated. A vial of tuberculin purified protein derivative was found with an open date of 11/24/25, and the LPN did not know how long it remained usable after opening. A Hepatitis B vaccine syringe with an expiration date of 7/7/25 was also stored in the refrigerator, and the LPN acknowledged it should not have been there. A metal box containing insulin and narcotics from the pharmacy was found in the refrigerator; it was locked but not permanently affixed, and staff stated the narcotics could not be moved to the refrigerator’s lock box due to pharmacy key and assignment issues. The DON later confirmed the narcotics box should have been permanently attached to the refrigerator. In the west hall medication cart, surveyors found multiple loose, unlabeled pills in drawers, including three small round white pills and several identified tablets (duloxetine, Lasix, atorvastatin in multiple strengths, divalproex, pantoprazole, and quetiapine), and the LPN acknowledged these loose pills should not have been in the cart. A bottle of Evencare ProView glucose test strips in use for a resident’s blood sugar check lacked an open date, and the RN using them stated the bottle should have had an open date but was unsure how long the strips were good after opening, despite the operator’s manual specifying dating and discard timeframes. Additionally, an unattended medication cart was observed near the nurses’ station with a round white pill on the floor nearby; the LPN later stated she had dropped the medication earlier, could not find it, and admitted she should have moved the cart to locate and destroy the medication but had not done so.
Expired Floor Stock Medication Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of medication storage when, during observation of the North Hall medication cart on 04/13/2026 at 08:10 AM, they found four acetaminophen 650 mg suppositories with an expiration date of 3/2026 still present as floor stock. Certified Medication Aide R confirmed at 08:15 AM that medication aides or nurses were responsible for discarding expired medications. On 04/15/2026 at 02:30 PM, Administrative Nurse E also verified that medication aides or nurses were expected to check the medication cart and discard expired medications. The facility’s Medication Labeling and Storage policy, dated 01/22/2026, required that medications be labeled and stored in accordance with facility requirements and State and Federal laws, and that floor stock medications be kept in the original manufacturer’s container with the expiration date and lot number clearly evident, yet the expired acetaminophen suppositories remained on the cart. No specific residents or their medical histories were mentioned in relation to this deficiency, and the findings were limited to the presence of expired stock medication on the North Hall medication cart and staff acknowledgments of their responsibility to remove such medications.
Expired Medications and Unsecured Treatment Cart
Penalty
Summary
Surveyors found that the facility did not comply with its own medication storage policy and federal requirements for labeling and storage of drugs and biologicals. In the North Unit medication room, an observation revealed multiple expired items that had not been removed from inventory, including blood collection tubes with expiration dates ranging from the previous year to earlier in the current year, anaerobic and aerobic blood culture bottles past their expiration dates, glycerin swab sticks, hydrocortisone packets, hydrocolloid and foam dressings, Huber needle sets, and a silicone contact layer. The facility’s policy dated 1/5/26 required that outdated, contaminated, or deteriorated medications and those in compromised containers be immediately removed from inventory. An LPN confirmed during interview that the identified items were expired. On a separate unit, surveyors observed a treatment cart that was unsecured inside a supply room with the door propped open. The cart contained two bottles of peroxide, one bottle of rubbing alcohol, multiple bottles of resident-specific ammonium lactate 12% lotion, several tubes of triamcinolone acetonide cream, and various bandages and gauze. The RN Assessment Coordinator confirmed that the treatment cart should be secured when unattended and that the supply room door should not be propped open. The Nursing Home Administrator later confirmed that the facility failed to ensure out-of-date medications were discarded in one medication room and failed to properly secure the treatment cart inside a propped-open supply room door.
Plan Of Correction
The DON/designee completed an OTC medication room audit on 3 units (North, South, West) for expired medications; all expired medications found were destroyed. The DON/designee will educate nursing staff on storing over-the-counter (OTC) medication according to manufactures guidelines for labeling and expiration dates, and ensure that treatment carts and the treatment room are locked. This education will also be part of the Nursing New Hire process during orientation. Audits will be completed by the DON/designee on the storage of OTC medication according to manufacturer guidelines for labeling and expiration dates, and ensuring treatment carts and treatment rooms are locked. These audits will be done four times weekly and three times monthly. The QAPI committee will review the results of these audits for further recommendations.
Failure to Label Insulin Pen and Remove Expired Stock Medications
Penalty
Summary
Surveyors found that the facility failed to properly label and store medications and biologicals as required by facility policy and professional standards. During observation of the 100–200 hall medication cart at 8:05 AM, an insulin pen (Novolog) for Resident 41 was found without an open date or discard date. In a separate observation of the treatment cart at 8:15 AM, four bottles of stock medications were found to be expired: aspirin 325 mg (expired 01/26), vitamin D tablets (expired 03/26), calcium 600 mg with vitamin D 5 mcg (expired 07/25), and zinc 50 mg tablets (expired 01/26). A certified medication aide confirmed that the stock medications were expired, and a licensed nurse confirmed the insulin pen was undated and stated that staff were supposed to date insulin pens when opened. The facility’s Medication Storage policy, dated 03/2026, stated that all drugs and biologicals would be stored in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals would not be used and would be returned to the pharmacy or destroyed per state regulations. These observations and staff confirmations demonstrated that the facility did not ensure insulin pens were dated when opened and did not remove expired stock medications from use, contrary to its own policy and accepted standards for medication storage and labeling.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and biologicals when multiple medication and treatment carts were found unlocked and unattended in facility hallways. During the initial tour on 04/06/26 at 07:50 AM, a treatment cart on Holiday House was observed unlocked and unattended; it contained one resident’s enteral medications, resident supplies, and PRN creams. At 08:10 AM the same day, a treatment cart on another unit was found unlocked and unattended, containing residents’ treatment supplies, PRN creams, and two insulin pens. At 08:20 AM on 04/06/26, a medication cart on that same unit was observed unlocked and unattended in the hallway with three insulins and creams for treatments inside. On 04/07/26 at 07:36 AM, another medication cart on the same unit was again observed unlocked and unattended in the hallway, containing scheduled medications and over-the-counter medications. During interviews, a licensed nurse stated that treatment and medication carts should be locked when out of the nurse’s view, and an administrative nurse confirmed that medication and treatment carts should be locked when not being used. The facility’s Medication Labeling and Storage policy dated 01/30/26 documented that medications would be labeled and stored in accordance with facility requirements and Kansas and Federal laws, including appropriate and safe labeling of medications dispensed to all residents.
Failure to Secure and Properly Manage Medications and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to properly secure and label medications and treatment supplies. Surveyors observed multiple treatment carts unlocked and unattended in hallways on several occasions. One treatment cart was found unlocked and unattended outside a resident room in the morning and again at midday, and a second-floor treatment cart was also left unlocked and unattended in the South hallway. Staff, including an RN and LPNs, confirmed that these carts were left unlocked and unattended at the times observed. In addition, the East Hall medication cart contained opened ipratropium bromide, albuterol, and fluticasone that were not dated as required, which was confirmed by an LPN. The deficiency also includes treatment medications left at residents’ bedsides instead of being properly stored. For one resident, surveyors observed a container of Vashe (hypochlorous acid wound cleanser) and a tube of zinc oxide on the nightstand while the resident was out of bed in a wheelchair; an LPN confirmed these items were present on the nightstand. For another resident, a tube of triamcinolone cream was observed on the bedside stand while the resident was sitting out of bed in a chair, and this was also confirmed by an LPN. These observations demonstrate that medications and treatment products were not consistently stored in locked compartments or otherwise secured in accordance with professional standards and facility policy.
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