Loose Controlled Medication Found in RN Medication Cart
Penalty
Summary
A deficiency occurred when a loose Tramadol 50 mg pill, a controlled medication, was found unsecured in the bottom drawer of a locked RN medication cart during an observation. The pill was identified by an RN, who confirmed it was not properly secured, administered, or disposed of according to facility policy. The RN stated that it was the responsibility of staff administering medications to check their carts before use, and that all medication counts had been correct that morning. There were no previous discrepancies reported with the narcotics count, including Tramadol, and the RN indicated she would complete an incident report regarding the loose medication. Interviews with nursing leadership, including the RCN, ADON, and Traveling DON, confirmed that the presence of a loose controlled medication in the cart could mean a resident did not receive their prescribed pain medication, and there was potential for diversion. An audit was performed for the two residents prescribed Tramadol, and the counts were found to be correct, suggesting the pill may have fallen out during preparation. The facility's policy requires controlled substances to be handled in accordance with federal and state laws, with only authorized personnel having access. The ADM stated that controlled medications should be kept in a lock box and that the loose pill in the cart indicated a resident may not have received their ordered medication.