Medications and Controlled Substances Not Properly Secured
Penalty
Summary
The facility failed to ensure that medications, including controlled substances, were properly secured and inaccessible to unauthorized staff. According to the facility's own policy, only authorized licensed nursing and pharmacy personnel should have access to controlled medications, and the access system for these medications should be separate from that used for non-scheduled medications. However, observations revealed that the supply room, which contained over-the-counter medications and an emergency kit (E-Kit) with controlled substances such as morphine, Xanax, and Temazepam, could be accessed by all staff, including CNAs, due to a keypad with an exposed spring that allowed the door to be opened without entering a security code. The E-Kit and medications had been moved to the supply room following a pharmacist's recommendation due to temperature concerns in the medication room. Interviews confirmed that the supply room was accessible to all facility staff because it also contained personal care supplies needed for residents. The DON acknowledged that the E-Kit in the supply room posed a potential hazard since controlled medications were accessible to unauthorized staff. Maintenance staff were unaware of the security flaw with the keypad, and the Administrator confirmed that all staff had access to the room and was not aware that the security code could be bypassed. These actions and inactions resulted in medications not being properly secured as required by facility policy and regulatory standards.