Medication Cart Found Unclean with Loose Pill and Debris
Penalty
Summary
A deficiency was identified when a medication cart serving rooms 109-120 was found to contain a loose, unidentified pill and scattered debris, including powdery and sticky substances, in multiple drawers. During observation, an LVN using the cart was unaware of the loose pill and did not remove it or clean the debris. The LVN acknowledged that the cart should be clean and free of loose pills, and stated that while maintenance sometimes pressure washes the carts, nurses are responsible for wiping down bottles and keeping the cart clean. The LVN believed that resident medications were not at risk because the medications were sealed, but agreed the cart should be wiped down. Interviews with the DON, ADONs, and Administrator revealed that responsibility for ensuring medication carts are clean and free of expired or loose medications is shared among ADONs, who are to check and clean the carts weekly, and the nurses who use the carts, who serve as a backup. The dirty medication cart was attributed to being possibly overlooked. The facility's policy requires that medication storage areas be kept clean, but the observed condition of the cart did not meet this standard.