Medication Cart Security and Improper Drug Disposal
Penalty
Summary
Facility staff failed to adhere to medication security protocols during medication administration. Specifically, a Registered Nurse (RN) was observed leaving the medication cart unlocked while administering medications to multiple residents. The cart remained unlocked while the RN entered resident rooms, took vital signs, and washed hands, with the cart unattended in the hallway. During this time, other staff and residents were present in the area, and the cart was accessible to individuals other than the RN. The cart was only locked after several residents had received their medications. Additionally, the RN did not follow proper procedures for disposing of a wasted medication. After spilling a dose of Glipizide ER 5 mg, the RN placed the medication directly into a trash receptacle instead of using the designated pill buster for disposal, as required by facility policy. The RN acknowledged the error when questioned by the surveyor. These actions were observed and discussed with the facility administrator.