Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and security practices. The main medication room near the front entrance and administration offices was repeatedly found to have a malfunctioning door handle and lock, resulting in the room being left unlocked and unsecured on several occasions. Staff, including RNs and the DON, acknowledged the issue and stated that maintenance had attempted repairs, but the door continued to fail to latch and lock properly. During these times, the medication room was accessible to unauthorized personnel, and there were periods when no staff were present to monitor access. In addition to the unsecured medication room, an inspection of a medication cart revealed loose, unidentified pills in multiple drawers and a plastic bag containing a tube of prescription medication dated over a year prior. The LPN accompanying the surveyor stated that nurses are responsible for cleaning the carts and ensuring medications are not left loose or mixed, but acknowledged that such issues should not occur. Furthermore, the main medication room contained multiple pharmacy totes on the floor, filled with medications from discharged or deceased residents and discontinued prescriptions. These included high-alert medications such as vancomycin IV bags, immunization vials, antidepressants, injectable blood thinners, insulin pens, and lidocaine patches. The LPN was unsure why these totes had accumulated and reported that pharmacy typically picks them up nightly, but they had been present for several days. Facility policy requires all drugs and biologicals to be stored securely in their original containers, with proper labeling, and in locked compartments accessible only to authorized personnel. The policy also mandates that discontinued or outdated medications be returned to the pharmacy or destroyed, and that medication storage areas be kept clean, safe, and orderly. The observed practices, including unsecured storage areas, accumulation of unreturned medications, and improper handling of medication carts, were inconsistent with these requirements and contributed to the cited deficiency.