Emergency Medication Kit Not Properly Secured
Penalty
Summary
The facility failed to ensure that the emergency medication kit (E-kit) was properly secured in accordance with facility policy and professional standards. During an observation in the medication room, the E-kit was found sitting on the counter with a black zip tie on the closure and a red numbered zip tie, which is the standard security measure, loosely placed over it. The red zip tie could be easily removed without being cut, indicating it was not securely fastened. An LPN present was unaware of why the red zip tie was not properly secured, despite facility policy requiring the E-kit to be locked with a red numbered zip tie and checked at each shift change by two licensed nurses. The number on the zip tie matched the documentation in the E-kit count book, and a count confirmed all medications were present. The director of nursing and administrator acknowledged the findings and confirmed that staff are expected to ensure the E-kit is properly secured at each shift change.