Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, labeled as cart A and cart B, were left unlocked and unattended in the facility. These observations occurred in the facility's lobby and were confirmed by interviews with two licensed nurses, both of whom acknowledged that the carts should have been locked at all times. The Director of Nursing also confirmed that medication carts are required to be locked to prevent drug diversion. A review of the facility's own policy on medication storage, dated 2024, indicated that all drugs and biologicals must be stored in locked compartments. The failure to keep the medication carts locked and attended was identified during a survey for a facility with a census of 93 residents. The unlocked carts contained medications, and the staff interviewed recognized that leaving them unsecured could allow unauthorized access. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based on the direct observation of the unlocked and unattended medication carts.
Plan Of Correction
Civil, criminal action or proceedings against the provider or its employees, agents, officers, directors, or shareholders. The provider reserves the right to challenge the cited findings if at any time the provider determines that the disputed findings are relied upon in a manner adverse to the interest of the provider either by the governmental agencies or third parties. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and California Evidence Code Section 1151 and should be inadmissible in any proceeding on that basis. F761 Label/Store Drugs and Biologics How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 04/03/2025, upon discovery of medication cart being unlocked, Licensed Nurse 1 and Licensed Nurse 2 immediately locked both carts. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B) DON / designee completed an audit on 04/03/2025 of medication carts to ensure all were locked. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C) An in-service was initiated by facility DSD / DON on 04/03/2025 and will continue until completion of 100% of Licensed Nurses regarding the importance of locking medication carts. D) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. How the facility plans to monitor its performance to make sure that solutions are sustained: E) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. Any issues identified during the audit rounds will be brought forth to the Department Managers five days a week during the morning meeting for review and immediate resolution. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. The Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.