Failure to Secure Medications and Restrict Access to Controlled Substances
Penalty
Summary
The facility failed to ensure that medications, including controlled substances, were securely stored and inaccessible to unauthorized individuals. Observations revealed that keys to a medication cart, which also opened a drawer containing controlled medications, were left unattended on an open shelf beside water cups, making them accessible to visitors and unauthorized persons. Additionally, a medication cart was found unlocked and unattended in a hallway, with no staff present in the vicinity. Further investigation showed that the medication room, secured by a keypad, was accessible to not only licensed nursing staff and certified medication aides, but also to the administrator and maintenance director, both of whom knew the keypad code. The maintenance director had entered the medication room alone on multiple occasions for non-medication-related tasks. Inside the medication room, a refrigerator containing a lock box with a bottle of liquid lorazepam (a controlled medication) was found unlocked, and the lock box itself was not secured. Interviews with staff, including the DON, confirmed that the administrator and maintenance director had access to the medication room and, consequently, to controlled medications, contrary to facility policy. The DON was aware that the refrigerator was not locked but was not aware that the lock box for controlled medications was also unsecured. Facility policies reviewed indicated that access to narcotics should be limited to licensed staff and the DON, and that medications should be stored in locations accessible only to designated staff, with medication carts kept locked when not in direct view of the administering staff.