Unsecured Medication Carts and Improper Medication Management
Penalty
Summary
Facility staff failed to keep treatment and medication carts locked when unattended and did not properly date or discard medications and biologicals as required. On two separate nursing units, surveyors observed unlocked and unattended carts containing prescription ointments, creams, and various medications. Some medications, such as Mupirocin ointment, were found without caps, and others, like Ketoconazole cream and Betamethasone Dipropionate, were dispensed months prior and not discarded. Additionally, medication cups with unidentified pills were found in the cart drawers without any resident names or labels. Further review revealed that insulin vials and pens were not dated when opened, and some, such as Lispro insulin, were kept beyond the manufacturer's recommended 28-day use period after opening. Staff members present during these observations acknowledged the lapses, with one LPN unable to explain the presence of multiple medication cups or the correct expiration period for insulin. The facility's own policy requires that medication carts be locked when unattended and that all medications be properly labeled and discarded when expired, but these procedures were not followed during the survey.