Medication Security and Storage Deficiency
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) prepared a resident's medication by placing multiple prescribed drugs into a medication cup and labeling it with the resident's name. The LPN placed the cup in the top drawer of the medication cart after the resident declined to take the medication immediately, stating she wanted to use the bathroom first. The LPN then left the medication cart unlocked and unattended while preparing and administering medication to another resident. The cart remained unlocked and unattended for several minutes before the LPN returned and locked it. The resident involved had a complex medical history, including aortic valve stenosis, muscle weakness, dysphagia, congestive heart failure, diabetes, and other chronic conditions. The Director of Nursing (DON) confirmed that professional practice requires medication carts to be locked when not in use or not under direct supervision by a licensed nurse, and that medications should not be pre-poured and stored in the cart for later administration. The observed actions did not comply with professional standards for medication security and storage.