Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with professional principles. During an observation of medication administration, a Licensed Practical Nurse (LPN) on the 2nd floor left a medication cart unlocked and unattended while using the telephone at the nursing station. The LPN acknowledged that the cart should have been locked when unattended, even though it was within sight. Additionally, a medical item was left on top of the cart, which should have been stored in the treatment cart. Another incident involved a Registered Nurse (RN) administering medication on the 2nd floor. The RN administered 15 ml of a solution as documented in the Electronic Medication Administration Record (EMAR), despite the bottle being labeled to administer 30 ml daily. This discrepancy between the labeled orders and the EMAR indicates a failure to follow proper medication administration protocols. The facility's policy on medication storage emphasizes that medications and biologicals should be stored safely and securely, accessible only to authorized personnel.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by the deficient practice. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All medication carts were audited for medications left unattended, and carts left opened at the time, no other deficiencies were found at the time. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? All nurses will be educated on locking their medication carts, and ensuring no medications are left unattended. Random audits will be conducted weekly by the Pharmacy representative and/or designee. Any deficiency found will be addressed immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.