Loose and Unlabeled Medications Found in Medication Carts
Penalty
Summary
Surveyors observed that two medication carts, one on B-hall and one on D/E-halls, contained 17 assorted loose tablets and capsules each, stored in the same drawers as blister packs for residents' medications. These loose medications were not labeled, and staff could not determine which residents they belonged to or how long they had been in the carts. The facility's policy required routine inspection and removal of medications with missing labels, but this was not consistently followed. Interviews with nursing staff, including an LVN, the ADON, and the DON, revealed that there was no official policy on how often medication carts should be cleaned, and each nurse was responsible for their own cart. Staff stated that loose medications should be disposed of properly, but there was no documentation or evidence that this was being done regularly. The staff were unable to identify the medications or their intended recipients, and acknowledged that the presence of loose medications could result in residents losing their prescribed doses.