Failure to Secure Medication Room and Controlled Substances
Penalty
Summary
A deficiency was identified when the medication room in the sub-acute area was found to be unsecured during an observation. The door to the medication room, which was supposed to be secured with a number-coded lock, could be opened without entering a code. Inside the medication room, a refrigerator containing an emergency kit (e-kit) with a vial of lorazepam, a controlled medication, was also found to be unlocked, with the keyed padlock hanging on a hinge. These observations were made in the presence of a nurse supervisor, who confirmed that the e-kits were supposed to be stored in a locked refrigerator and acknowledged that a mechanism keeping the door unlocked had been engaged. Further interviews with facility staff, including the DON, confirmed that all medication rooms and medication storage areas were required to be locked at all times to prevent unauthorized access. A review of the facility's policy indicated that medication supplies should only be accessible to authorized personnel and that controlled medications must be stored in a double-locked compartment. The failure to secure both the medication room and the refrigerator containing controlled substances constituted a breach of these policies.