Medications Left Unsecured During Administration
Penalty
Summary
Surveyors observed that the facility failed to securely store medications during medication administration for two residents. Specifically, a registered nurse (RN) left multiple multi-dose medication bubble cards, including prescription and over-the-counter drugs, on top of a medication cart in a high-traffic hallway while administering medications to residents. During these times, the medication cart was unattended as the RN walked away to assist residents, and other staff and residents passed by the cart, leaving the medications accessible and unsecured. The facility's policy requires all drugs and biologicals to be stored in locked compartments or under the direct observation of the person administering medications. However, the RN confirmed that medications were left unattended on the cart, in violation of this policy. The medications left unsecured included Vitamin B-12, Carafate, Lipitor, Apixaban, Lasix, Zestril, Toprol XL, Potassium Chloride, Hydrodiuril, Preservision, and Zoloft. The events were confirmed through observation, interview, and review of facility policy.