Failure to Secure, Label, and Date Medications on Medication Cart
Penalty
Summary
Facility staff failed to properly store, label, and secure medications and biologicals on at least one medication cart. During a medication pass, a nurse left a resident's medications unattended on top of an unlocked medication cart while leaving the room to obtain manual blood pressure cuffs. The medication cart remained unlocked and unattended during the process, and the nurse also left the resident's room door open while administering medications, without pulling the privacy curtain. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had multiple complex medical diagnoses, including chronic atrial fibrillation, stroke, and diabetes. Additionally, an inspection of the medication cart revealed several topical medications and creams that were opened but not dated or labeled with a resident's name. Staff interviews confirmed that there was no consistent practice for dating opened medications, and the facility lacked a policy on this matter. The Director of Nursing and Consultant Pharmacist acknowledged that the pharmacist typically placed the opened date on ointments, but this was not consistently done, and staff were unsure of the effectiveness of undated medications.