Unsecured Medications Left Unattended at Nurse Station
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for two residents by not properly securing physician-ordered medications. For one resident with diagnoses including peripheral vascular disease, dementia, and Parkinsonism, medications Cilostazol and Memantine HCI were found unsupervised on the desk at the nurse station. This resident was severely cognitively impaired and dependent on staff for most activities of daily living. For another resident with type 2 diabetes, hypertension, and anemia, Metoprolol was also found unsupervised on the same desk. Both residents' medication orders were confirmed through record review. During an observation and interview, an LVN admitted to placing the medications on the desk while changing them out from the medication cart, acknowledging that they should have been disposed of in the medication room according to facility policy. The LVN further stated that the medications were not disposed of properly and that other residents could have accessed them. An RN confirmed that the medications should not have been left on the desk and reiterated the facility's policy for medication destruction, which requires documentation and proper disposal in the incineration container. Review of the facility's policy supported these procedures for medication destruction.