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F0761
E

Unlocked Treatment Cart and Medication Labeling Discrepancy

Olympia, Washington Survey Completed on 05-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that Treatment Cart 1 was repeatedly left unlocked on multiple occasions, despite containing various medications such as antifungal powders and creams, hydrocortisone cream, lidocaine ointment, zinc oxide paste, estradiol vaginal cream, clobetasol propionate, and Thera-Honey gel, as well as wound care supplies. Staff, including a Registered Nurse and the Director of Nursing Services, confirmed that the expectation was for the treatment cart to be locked, but it was found unlocked during several observations. Additionally, a review of medication records for a resident revealed a discrepancy between the Medication Administration Record (MAR) and the medication bubble pack. The MAR indicated an order for Lisinopril 20 mg, with instructions to give half a tablet via PEG tube twice daily, while the medication bubble pack was labeled for Lisinopril 10 mg, instructing to give one tablet via tube twice daily. Staff acknowledged that the orders should match and recognized the potential for a dosing error due to this inconsistency.

See complete original report
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