Medication Storage Deficiency
Penalty
Summary
The facility failed to provide appropriate storage of medications on one of the three medication carts observed. During an observation of medication Cart #3400 with a Registered Nurse (RN), three loose round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. The RN revealed that the medication carts are cleaned daily on every shift, indicating a lapse in maintaining the medication cart in a secure and orderly manner. Additionally, during an observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON), the lock box in the refrigerator was found unlocked. The lockbox contained an emergency kit with five vials of medication. The ADON attempted to secure the lock box with several keys but was unsuccessful, stating that the lock was warped and this issue had not been reported prior to the survey. The facility's policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On , Staff C immediately discarded the 3 round white pills and empty medication packaging found in the second drawer of Medication Cart #3400. Staff C and ADON immediately deep clean Medication Cart #3400. On the lock box was repaired. On the lock box was replaced with a new lock box. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all medication carts to ensure cleanliness of all medication carts. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. 3. The Director of Nursing, or designee(s) will educate all staff on Label, Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2), 59A-4.112(6), FAC Drug Storage and facility's Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.