Failure to Secure Medications and Supervise Administration
Penalty
Summary
Facility staff failed to ensure the safe storage and supervision of medications in accordance with professional standards and facility policy. Observations revealed that medications were left unattended on top of the medication cart, and the cart itself was left unlocked and unsupervised in multiple instances. The key to the narcotic lock box was left in the lock with no nurse present, and staff were observed walking away from the cart while it remained accessible to others. These actions were in direct violation of the facility's own policies, which require all drugs and biologicals to be stored in locked compartments and not left unattended. Additionally, staff did not properly supervise residents during medication administration. On several occasions, medication aides placed medication cups in front of residents and walked away without ensuring the medications were taken, relying solely on verbal confirmation from the residents. Interviews with staff confirmed that residents were not supervised during medication administration, and the Director of Nursing acknowledged that medications should be locked and residents should not receive medications without staff supervision. These failures were observed among a sample of 19 residents, with a facility census of 31.