Unrestricted Access to Medication Storage Rooms by Non-Qualified Staff
Penalty
Summary
The facility failed to ensure that access to medication storage rooms was limited only to qualified staff, as required by policy. During multiple observations, the maintenance supervisor was able to open medication storage rooms using their own key without the presence of licensed nursing personnel. On several occasions, the maintenance supervisor accessed these rooms alone or called for a nurse only after the room was already open. Both the medication storage room by the DON's office and the one on hall 500 contained numerous containers of residents' medications at the time of access. Interviews with staff confirmed that the maintenance supervisor, along with nurses and medication aides, had access to the medication storage rooms. The DON stated that the maintenance supervisor was allowed access due to the presence of a fire panel control in one of the rooms, but was supposed to be accompanied by nursing staff. Facility policy, however, specified that only licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications should have access to the medication supply. No controlled medications were reported to be stored in these rooms at the time.