Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments and did not restrict access to authorized personnel only. Specifically, an unlocked dialysis medication cart containing intravenous medications, including Heparin and Zemplar, was found in a resident's room. Additionally, dialysis fluids were left unsecured on the resident's bedroom floor. The resident, who had end-stage renal disease and severe cognitive impairment, reported that an outside agency used the cart and fluids for in-room dialysis, and was unaware that the medications and fluids were left unlocked. Facility staff, including the RN and DON, confirmed that both the contract dialysis nurse and facility nursing staff were responsible for ensuring these items were secured, but acknowledged the oversight. Another incident involved an unsecured and unattended Advair Diskus inhaler found in a common area near the nurse's station. The inhaler, which was not labeled with a resident's name and had 57 doses remaining, was left in the basket of a vital sign machine with no staff or residents present. When shown the medication, an LVN acknowledged that it should have been locked on a cart and immediately removed it to secure storage. Facility leadership, including the ADM and DON, stated that nurses and medication aides were responsible for maintaining medication security and that environmental rounds were conducted to monitor for unsecured medications. A review of facility policy confirmed that medications and biologicals are to be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. Despite this policy and staff training, the survey identified lapses in medication security, with medications left unlocked and unattended in both resident rooms and common areas.