Unattended Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and confirmed with the nearest room that the assigned nurse was not present. Approximately ten minutes later, a wound care nurse returned to the cart and acknowledged that it should have been locked when unattended, explaining that the cart was left unlocked by mistake while assisting a resident. Further interviews with the Director of Nursing confirmed that facility protocol requires medication carts to be locked when not attended. Review of the facility's policy on Medication Labeling and Storage also states that all medications and biologicals must be stored in locked compartments accessible only to authorized personnel. At the time of the survey, there were 131 residents in the facility.
Plan Of Correction
Citation: F580 (D/N199-Class: Iif, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Following this, audits will be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet; ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The findings of audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025 --- F761 (D/N95-Class: III, Isolated) On 06/17/2025, Staff A locked the medication/treatment cart after an interview with the surveyor. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents who have the potential to be affected by this deficient practice. On 6/22/2025, the Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. Frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025