Failure to Secure and Properly Store Medications
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and professional standards. Multiple incidents were observed where staff left medications unattended and out of sight, including a vial of insulin left on a medication cart and oral medications stored in a cup on the cart. In one instance, opened oral medications intended for a resident were found in a medication cup inside the medication cart, and the responsible LPN confirmed these were not disposed of as required. Additionally, a resident's inhaler was found stored on an over-the-bed table without an opened date, and staff confirmed this was not an appropriate storage location. Further observations revealed that medication carts on several halls were left unlocked, unattended, and out of staff sight. Staff interviews confirmed that medication carts should not be left unsecured or unsupervised, and that medications should not be left on top of carts or at residents' bedsides. The Director of Nursing and other staff acknowledged these lapses in medication security and storage practices during interviews. Physical inspection of medication carts on multiple halls revealed significant structural deficiencies, including holes and cracks in the drawers. These defects were large enough to allow access to medications stored inside, and staff confirmed awareness of the damage but had not reported it to management. The facility's failure to maintain secure storage for medications and to ensure staff compliance with medication handling protocols resulted in multiple deficiencies related to medication security and storage.