Failure to Secure Medication Storage and Properly Label Prepared Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not stored securely in the facility, as required by professional standards and facility policy. During continuous observation, a registered nurse left a medication cart unattended and unlocked, with the cart out of her line of sight. This allowed for the possibility of unauthorized access to medications. The nurse confirmed that she had left the cart unlocked while attending to a resident in another room. Additionally, during medication administration, three medication cups containing various pills with illegible labels were found in the top drawer of the medication cart. The nurse admitted to preparing these medications for residents who were not present in their rooms and placed the cups in the drawer to administer later, as she was behind schedule. She was unable to identify the medications or the intended residents for each cup. Facility policy requires medications to be prepared and administered one resident at a time, with immediate documentation, and for medication carts to be locked when not in direct view. Interviews with the DON and Regional Clinical Manager confirmed that these practices were not in accordance with facility policy.