Failure to Properly Label and Secure Controlled Medications on Nurses Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on the D hall Nurses Cart were not labeled and stored in accordance with professional standards. Specifically, a blister pack containing APAP/codeine 300-30 mg tablets for a resident had one blister seal broken, with the pill still inside and taped over. The RN responsible for the cart stated that while narcotic counts were performed at shift change, she did not check the integrity of the blister packs during the count and was unaware of when or how the seal was broken. The RN acknowledged that nurses are responsible for checking for broken seals during shift changes and that any broken-seal medication should be wasted with another nurse present. The DON confirmed that any medication with a broken blister pack seal should be discarded and that it was not acceptable to keep a pill in an opened blister pack, citing risks of drug diversion and infection control. The DON also stated that nurses are responsible for checking medication blister packs during shift changes and that ADONs are expected to randomly monitor the carts. Facility policy requires that medications in containers without secure closures be immediately removed and disposed of according to procedures.