Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored in locked compartments as required. The long-term care medication room was found unlocked and open without staff supervision, with both over-the-counter and prescribed medications accessible inside. The Director of Nursing (DON) confirmed that the medication room was supposed to be locked at all times, but acknowledged that nurses might not fully close the door, resulting in it being left open and unlocked. Facility policy requires all medications and treatment items to be stored in a locked cabinet or room, inaccessible to patients and visitors. Additionally, a 10 cc syringe of normal saline intended for flushing a resident's peripherally inserted central catheter (PICC) line was found unattended on the resident's nightstand while the resident was sleeping. The resident had been admitted with multiple diagnoses, including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, and had physician orders for intravenous antibiotics and saline flushes. Both the LVN and DON confirmed that the normal saline should have been stored in a nursing cart rather than left in the resident's room, in accordance with facility policy.