Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified multiple failures in the secure storage and labeling of drugs and biologicals within the facility. The medication room, which was supposed to be locked at all times when not in use, was repeatedly observed with a padlock that was not engaged, leaving the room accessible without a key. Nurses were seen entering and exiting the medication room without locking it, and the padlock was consistently left unsecured, even when no licensed nurse was present or in direct view. Staff interviews confirmed a lack of understanding or adherence to the locking procedure, despite facility policy requiring the medication room to be locked when not in use. Additionally, the treatment cart containing topical creams, sprays, and ointments was observed on several occasions to be left unlocked and unattended in the hallway, accessible to residents and others. Nursing staff acknowledged that the cart should be locked at all times when not in direct use, but this was not consistently practiced. The clean utility room, which contained various topical treatments, was also found with its door open and cabinets unlocked, contrary to the expectation that it remain closed and locked to prevent resident access to hazardous items. Specific residents were also affected by improper storage of medications. One resident with a stage four pressure ulcer had a bottle of Daikin solution, a strong antiseptic containing bleach, left on their bureau rather than being securely stored in the treatment cart. Another resident with dementia and bullous pemphigoid had a container of Triamcinolone Acetonide Cream left on their dresser over multiple observations, despite staff acknowledging that such medications should be kept out of residents' reach. These actions were inconsistent with the facility's policy on safe and secure medication storage.