Failure to Secure and Properly Label Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. During an observational tour, an unlocked wound care cart was found on the East wing containing various resident prescription and over-the-counter topical medications, as well as wound care supplies. The cart was unattended and accessible to residents, visitors, and staff. A registered nurse admitted to being the last to use the cart and acknowledged it should have been locked. Additionally, an unlocked medication administration cart was observed on the East wing, containing twenty-four active prescription and OTC medications, all unsecured and unattended. Both a licensed practical nurse and a registered nurse/unit manager confirmed that the cart should have been locked and not left unattended. On a separate occasion, a medication cart on the Center wing was found to contain a loose, unidentified pill in one of its drawers, which staff acknowledged should not have been present and should have been secured. Further, a medication storage observation revealed a bottle of Elder Tonic in a medication cart without an opening date label and with an unreadable expiration date. The LPN present could not provide the required information and stated that nurses are supposed to check for expiration and opening dates during shift changes. The DON confirmed that facility policy requires all medications to be properly labeled and secured at all times.