Failure to Secure Medications and Improper Resident Medication Storage
Penalty
Summary
Surveyors observed that a medication cart containing residents' medications was left unlocked and unattended in a hallway by a Licensed Vocational Nurse (LVN) during a medication pass. The LVN admitted to not locking the cart when retrieving medication from the medication room, acknowledging that the cart should have been secured for safety. The Director of Nursing (DON) confirmed that the medication cart needed to be locked if it was outside the licensed nurse's view. Facility policy and procedure documents reviewed by surveyors also required absolute security of medications, including locking medication carts when out of sight. Additionally, a resident with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD) was found to have a prescribed inhalation medication stored in their bedside drawer. The resident stated they kept their medication in the drawer, and the LVN confirmed this, stating that medications should not be kept at the bedside for safety reasons. The DON stated that residents were not allowed to have medication at their bedside unless they had been assessed for safe self-administration. Facility policy required written physician orders and interdisciplinary committee determination for residents to self-administer or retain medications in their rooms.