Failure to Secure and Properly Store Medications and Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to maintain medical products within expiration dates and in secure locations, as well as failed to have a system to secure access to controlled medications. Specifically, expired lubrication jelly packets were found in the emergency cart, and the Assistant Director of Nursing confirmed their use for airway procedures and acknowledged their expiration. Additionally, diabetic lancets were left unattended on a medication cart in a resident hallway without a nurse present, which was confirmed by both a nurse and the Director of Nursing as inappropriate. Further observations revealed that all four medication refrigerators in the facility lacked properly affixed or present narcotic lock boxes for controlled substances. In some cases, the narcotic box was unattached and could be removed with the shelf, while in others, the lock box was missing or the lock had been broken for at least a week. The Director of Maintenance was unaware of a repair request for the broken lock, and the facility's policy required a substantially constructed storage unit with two locks for controlled substances in areas without automated dispensing systems.