Improper Medication Storage on Unit 2
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper storage of medications and biologicals on Unit 2. Specifically, a Licensed Practical Nurse (LPN) pre-poured medications for a resident and left them unattended on top of an unlocked medication cart. This occurred while the LPN entered the resident's room to obtain their blood pressure, leaving the medications vulnerable to access by others. Interviews conducted with the LPN, a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that facility policy mandates that medication carts must be locked when not in view of the nurse, and medications should not be left unattended. The LPN acknowledged the risk posed by wanderers who could potentially take the medications left on the cart. The RN and DON reiterated the importance of securing the medication cart at all times, regardless of the duration it is left unattended.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. DON gave 1:1 counseling to LPN 1 regarding following the facilities protocol and procedure of medication administration, including procedure when leaving med cart unattended. b. DON issued disciplinary action to LPN 1. II. Identification a. DON and ADON observed all LPN's doing medication pass. b. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Medication Administration Policy on 3/3/25 and found it to be compliant. b. DON and ADON in-serviced all RN and LPN on 3/2/25 staff on proper handling of medication, proper use and storage of medication cart when stepping away from the cart. c. RN and LPN's will receive performance review every 6 months, and quarterly medication pass review for all LPNs and RNs. IV. Monitoring a. DNS and ADON developed an audit tool to ensure nursing staff compliance with proper medication administration. All LPNs will be selected at random and rotated as part of the audit to ensure compliance. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The ADON will be responsible to ensure correction of this deficiency.