Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored in accordance with professional principles, as observed during a recertification survey. Specifically, in the Unit 2 medication room, controlled substances were not properly stored in a double-locked cabinet. During an observation, it was noted that the second door of the cabinet was ajar, and the lock was not functioning, leaving multiple controlled medications unsecured. The facility's policy requires controlled substances to be stored in a locked container separate from non-controlled medications, and this container must remain locked at all times except when accessed for resident medications. Interviews with staff revealed that the issue with the narcotic cabinet lock had been ongoing for several days. A Licensed Practical Nurse noticed the malfunction two days prior to the survey and reported it to maintenance and the Assistant Director of Nursing, but the issue was not resolved. The Registered Nurse and Assistant Director of Nursing both acknowledged that the medications should not have been kept in the cabinet if the locks were not working and should have been moved to a secure location. The Director of Nursing was not informed of the issue until a week later, indicating a breakdown in communication and protocol adherence regarding the storage of controlled substances.
Plan Of Correction
Plan of Correction: Approved April 8, 2025 Corrective Actions for Residents Identified All controlled substances were removed from the cabinet and locked in appropriate storage immediately on 3/14/2025. The double locked cabinet for controlled medications (substances) on Unit 2 was fixed on 3/14/25 to ensure both locks are functioning. The RNS #1, LPN #2, and LPN #3 were in-serviced on medication storage on (MONTH) 14, 2025. Residents at Risk All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date and none were found. Systemic Change The facility policy titled "Controlled Substances" was reviewed, and no revision needed. All nurses are being in-serviced on "Controlled Substances" policy and procedure. New process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). All nurses are being in-serviced on this process by DNS. The audit tool was developed to monitor for compliance. Monitoring of Corrective Action On a weekly basis for one quarter, DNS or designee will inspect 2 med rooms and 2 med carts, to ensure compliance with controlled medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designees will report findings to Administrator. On a monthly basis, DNS or designees will report the findings to QAPI Committee. QAPI Committee to determine if further action is required. Responsible person: Director of Nursing