Failure to Secure Medications and Improper Medication Storage
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal requirements, as well as facility policy. Multiple incidents were observed where medication and treatment carts were left unlocked and unattended, sometimes out of the nurse's line of sight, and with medications left on top of the carts. On several occasions, nurses left carts open in hallways with residents and other staff nearby, providing full access to the medications. Interviews with the involved nurses confirmed that they were aware the carts should have been locked and medications should not have been left unattended or on top of the carts. Additionally, a resident with a history of malignant neoplasm of the kidney and urinary retention, who was assessed as not being able to self-administer or store medications at bedside, was found with a cup of pills left on the dresser by a nurse. The resident reported that the nurse had given the medications and left them at the bedside after the resident indicated they would take them later. Review of the Medication Administration Record confirmed that several medications had been administered in this manner, contrary to facility policy and the resident's assessment.