Failure to Secure Medication Carts and Properly Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely and in accordance with state and federal regulations. On multiple occasions, the medication treatment cart was found unlocked and unsupervised at the main nurse station, containing various medications and treatment supplies labeled as 'keep out of reach of children.' Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the cart should always be locked and that the key was kept in the medication room. Despite this, the cart was repeatedly left unsecured, and staff were unable to identify who last used it. Further inspection of the Hall 400 Nurse Cart revealed four loose pills and an opened Basaglar insulin pen that was not labeled with the date it was first opened. The LVN responsible for the cart acknowledged that staff are expected to check their carts daily for loose pills and ensure all medications are properly labeled and stored in original pharmacy packaging. The DON confirmed that nurses are responsible for keeping medication carts clean, free of loose pills, and for labeling insulin with the date opened. A review of the facility's policy on medication labeling and storage indicated that medications must be stored in their original containers, and all compartments containing medications must be locked when not in use. The policy also stated that only the issuing pharmacy is authorized to transfer medications between containers, and that nursing staff are responsible for maintaining medication storage areas in a clean and safe manner. These observations and interviews demonstrated that the facility did not consistently follow its own policies or regulatory requirements regarding medication security and labeling.