Failure to Secure Medication Carts and Improper Medication Administration
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and securely stored in accordance with professional standards and facility policy. On multiple occasions, surveyors observed a treatment cart left unlocked and unattended in the hallway, as well as a crash cart in front of the elevator with broken plastic locks and an easily turned gray lock, making the contents accessible. Staff interviews confirmed that facility policy requires these carts to be locked when not in direct visual contact, and that the observed lapses were contrary to established procedures. Additionally, the facility's own policies specify that medication carts and supplies must be locked or attended by authorized personnel at all times. Surveyors also found that individual medications were not securely managed during administration. Two residents were observed with medication cups containing multiple pills left at their bedsides, with one resident unable to identify the pills and another stating that the nurse had left the medications for later consumption. Staff interviews revealed that medications should not be left at the bedside unless there is a physician's order and an assessment for self-administration, and that medications should not be signed as administered until the nurse has observed the resident take them. Facility policies reviewed by surveyors confirmed these requirements, but staff failed to adhere to them during the survey period.