Medication Cart Security Lapse
Penalty
Summary
Transitions Healthcare Washington PA was found to be non-compliant with federal and state regulations regarding the labeling and storage of drugs and biologicals. During an abbreviated survey conducted in response to a complaint, it was observed that a medication cart, referred to as 'A' cart, was left unlocked and unattended. The computer screen on the cart was open to the electronic medication administration record, which should have been secured. On top of the cart, there were various medications and medical supplies, including a pair of scissors, a bottle of Miralax, 13 bottles of over-the-counter medications, six bottles of liquid prescription medication, an intravenous antibiotic solution bag, and four medication blister packs. Interviews with staff revealed a lack of adherence to the facility's policy on medication storage. A Licensed Practical Nurse (LPN) acknowledged that the bottles on the cart were over-the-counter medications, while the Assistant Director of Nursing confirmed that medication carts should be secured when unattended, and medications should be stored inside the cart. The failure to secure the medication cart and its contents was a direct violation of the facility's policy and federal regulations, which require that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Immediately upon identification, all biologicals identified were secured including the scissors. The cart was locked, and the computer screen closed. The four other medication carts were checked and no other concern identified. Employee 1 was immediately provided education on the storage of biologicals policy and procedure. Education on the storage of biologicals policy and procedure has been completed with the licensed staff. On March 4, 2025, the Director of Nursing initiated visual cart inspections five days a week for four weeks. Results of audits will be taken to the next QAPI meeting on March 14, 2025, for review/discussion.