Failure to Secure Controlled Medications and Resident Drugs
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles, specifically by not having the lockbox for controlled medications permanently affixed to the refrigerator in one medication room. During an observation, the lockbox was found locked but not secured to the refrigerator, and staff interviews confirmed that it had previously been bolted but was no longer affixed. The Director of Nursing (DON) and the Administrator both acknowledged that the lockbox should have been permanently attached to prevent drug diversion, and neither could confirm when or why the bolts had been removed. Additionally, the facility failed to secure a resident's medication inside the locked medication cart. A medication card containing enalapril, prescribed for hypertension, was found left unattended and unsecured on top of the medication cart in a common area while the responsible nurse was away retrieving trays. The nurse admitted to leaving the medication card out and acknowledged that she was aware of the policy requiring all medications to be secured. Both the DON and the Administrator confirmed that all nurses were educated on the need to keep medications secured at all times.