Medication Cart Left Unlocked and Medication Labeling Error Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and secure storage of drugs and biologicals on two of four medication carts reviewed. Specifically, one medication cart (C/D Hall) was found unlocked and unattended in the hallway in front of the nurse's station. The DON confirmed that the cart was assigned to an LVN, who admitted to forgetting to lock it after becoming sidetracked. Facility policy requires medication carts to be locked or attended by authorized personnel at all times, and the DON acknowledged that leaving the cart unlocked was a safety concern. Additionally, a review of a resident's medication revealed that the pharmacy label on a bottle of Seroquel did not match the current physician's order. The label indicated a dosage of 50 mg at bedtime, while the physician's order specified 50 mg twice daily. The medication aide administering the drug recognized the discrepancy but stated she overlooked it due to being in a hurry. The DON confirmed that the facility's expectation is for staff to match medication labels to physician orders and apply a change of direction sticker if there is a discrepancy. Facility documents reviewed by surveyors outlined these requirements for medication storage and administration.