Failure to Secure and Properly Administer Medications
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and administration of drugs and biologicals. One nurse left a medication cart unlocked and unattended in a hallway, with an insulin pen left unsecured on top of the cart. The nurse acknowledged that she was responsible for ensuring the cart and medications were secured but failed to do so when responding to a resident's call light. Both the DON and Administrator confirmed that their expectation was for medication carts and medications to be locked and secured when not in direct view of authorized staff. Another deficiency was observed when a resident, who was legally blind and had multiple diagnoses including prostate cancer and depression, was found to have a bottle of wound cleanser in his bedside drawer. The resident reported that items were sometimes removed and returned to his room by staff. Facility leadership, including the ADON, DON, and Administrator, all stated that wound care items such as wound cleanser should not be stored in resident rooms and should be removed by nursing staff after treatments. A further incident involved a medication aide leaving a cup of medications on a resident's breakfast tray without ensuring the medications were taken. The resident, who had diagnoses including diabetes, schizoaffective disorder, and depression, was found with the full cup of medication after breakfast. The medication aide admitted to leaving the medications due to being in a hurry, and facility leadership confirmed that medications should not be left at the bedside and that staff are expected to ensure medications are administered and swallowed before leaving the room.