Deficiencies in Controlled Medication Handling and Medication Storage
Penalty
Summary
The facility failed to ensure proper handling and documentation of controlled medications, as well as appropriate storage and monitoring of medication refrigerators. During a survey, it was observed that incoming and outgoing nurses did not consistently count controlled medications during shift changes, and there were missing signatures on the narcotic accountability sheets. In one instance, a nurse administered a controlled medication to a resident but did not immediately document the administration, resulting in a discrepancy between the number of capsules recorded and the actual count in the medication dispensing card. Another nurse was unaware of the proper procedures for repackaging medications and could not identify who had repackaged a resident's medication into pill sleeves, which was not in accordance with facility policy. Additionally, the survey revealed that one of the medication refrigerators lacked a temperature log sheet, and the other had an outdated log, contrary to facility policy requiring daily temperature monitoring to ensure safe medication storage. The absence of current temperature logs was acknowledged by staff, who stated that this could result in medications being stored at unsafe temperatures. Furthermore, personal food items belonging to staff were found stored in the medication refrigerator, which is prohibited by facility policy due to the risk of contamination and potential harm to residents' medications. The deficiencies affected two residents who were prescribed controlled medications for pain and seizure management. The facility's own policies require accurate documentation, proper storage, and regular monitoring of controlled substances and medication storage areas, but these procedures were not consistently followed as evidenced by the surveyor's observations and staff interviews.