Improper Medication Storage and Handling
Penalty
Summary
Surveyors observed an unlocked medication cart on the Spring Unit with no licensed staff present. The cart had an open monitor displaying personal information for a resident, and an insulin pen was stored on top of the cart. Upon opening the top drawer, several clear medicine cups containing pills were found, including one cup with five pills identified as medications for a specific resident. Two other cups contained single white pills. A registered nurse later confirmed the medications and explained that the other two cups were intended to be wasted, one because the pill had fallen on the floor and the other because the medication was no longer ordered for the resident. The nurse did not provide a reason for not immediately wasting the medications or for removing a medication that was not part of the current order. The Director of Nursing confirmed that the observed practices did not align with facility policy, which requires all medications and biologicals to be stored in locked compartments and for medications to be under direct observation or locked during medication passes. The failure to lock the medication cart, improper storage of insulin, and the presence of unadministered and unaccounted-for medications in the cart constituted a breach of medication storage and handling protocols.