Failure to Properly Store, Label, and Secure Medications and Treatment Carts
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, as evidenced by multiple observations of opened medications, such as inhalers and liquid supplements, that were not dated upon opening. Manufacturer guidelines for these medications require discarding after a specified period post-opening, but staff did not label them with the date they were first used. Interviews with nursing staff, a unit manager, and the DON confirmed that medications with shortened expiration dates should be dated when opened, but this was not consistently done. Treatment carts containing medicated ointments and creams were repeatedly found unlocked and unsupervised on both the second and third floor units. Surveyors were able to access these carts, and multiple staff members and residents were observed passing by the unsecured carts. Staff interviews confirmed that treatment and medication carts are expected to be locked at all times unless attended by a nurse, but this protocol was not followed during the survey. Medication carts were also found to be disorganized and unclean, with observations including a bottle of liquid medication without a cover, loose pills, and a sticky red substance spilled inside the cart. Additionally, nursing staff left surveyors unattended with unlocked medication carts and in the medication room, contrary to facility expectations that staff should remain present during such inspections. These lapses were acknowledged by the staff, unit manager, and DON during interviews.