Failure to Properly Store and Identify Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in their original packaging or containers as required by policy and professional standards. Observations revealed that one resident had five unidentified pills left on her bedside table, and neither the resident nor the nursing staff could identify the medications or their origin. The resident, who had intact cognition and a history of rheumatoid arthritis, hypertension, and anxiety, was unsure about the purpose or duration of the pills' presence. The nurse practitioner acknowledged the resident's autonomy in self-administering medications but also recognized the potential risk if other residents accessed the pills. Additionally, staff interviews confirmed that facility policy required medications to be administered immediately after preparation and that unused doses should be disposed of according to policy. Further observations identified loose, unidentified pills in two medication carts. In one instance, twelve loose pills were found in a medication cart drawer, and the LPN on duty could not account for how they got there, noting that pills sometimes fell out of blister packs. Another observation showed a nurse preparing a resident's medications in advance and storing them in the cart before administration. An additional loose, unidentified tablet was found in a cup in another cart, with a medication aide admitting she did not want to waste the pill and initially considered returning it to the drawer. Facility leadership interviews confirmed expectations that staff verify medication ingestion and waste unused medications appropriately, but these practices were not consistently followed.