Failure to Properly Label and Secure Medications and Controlled Substances
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. In one instance, a resident with intact cognitive function was found with bottles of Rexall, Purzee, and Melatonin on his bedside table, which had been brought in by a family member. These medications were not listed in the resident's order summary report, and staff interviews confirmed that the medications should not have been at the bedside, as this could result in the resident or others taking them inappropriately. The medications were subsequently removed by staff after the issue was identified. In another case, a lock box containing two bottles of Lorazepam, a controlled substance, was found in the medication room refrigerator but was not permanently affixed as required. The DON and Administrator both acknowledged that the lock box should have been secured to prevent removal, and that it was their responsibility to ensure compliance with this requirement. The lack of proper affixation was recognized as a failure to secure controlled substances according to facility policy and professional standards. Additional deficiencies were observed with another resident who had a prescription cream left unsecured on his nightstand over multiple observations, despite having severe cognitive impairment and a care plan indicating risk for impaired skin integrity. Furthermore, medication aides were observed leaving a medication cart unlocked and unattended, with keys attached to the narcotic drawer, while administering medications to residents. Staff interviews confirmed that medication carts should be locked and keys kept in possession when not in use, and that these lapses were contrary to facility policy and expectations.