Unsecured Medication Cart and Expired Medications Found
Penalty
Summary
A medication cart on the South Wing was observed with its lock in the open position and left unattended at the end of a hallway, allowing unrestricted access to all drawers containing residents' medications. The cart was not attended by staff at the time of observation, and the drawers could be easily opened. The Director of Nursing Services (DNS) confirmed the cart was unsecured and unattended and was unable to explain why the responsible nurse had left it in that state. Additionally, expired medications were found in the emergency intravenous (IV) supply tackle box, including a liter of Normal Saline with potassium chloride, a bag of heparin IV flushes, and two Covid vaccines, all past their expiration dates. The DNS acknowledged that these medications were expired and stated that it was her responsibility to check the emergency medication box, attributing the presence of expired medications to an oversight. The facility's Medication Administration policy required medication carts to be kept closed and locked when out of sight of the medication nurse but did not address the storage of expired medications.