Failure to Secure and Properly Handle Controlled Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the secure storage and handling of controlled medications on three medication carts. During observations, surveyors found that blister packs containing tramadol 50 mg tablets for three different residents had broken seals, with the pills still inside the damaged blisters. In one instance, a broken blister was taped over rather than properly discarded. Nursing staff, including LVNs and an RN, reported that while narcotic counts were performed at shift changes, they did not check the integrity of the blister packs during these counts and were unaware of when or how the seals were broken. The staff acknowledged that the correct procedure would be to discard any pills from broken blisters with another nurse present, but this was not consistently followed. The Director of Nursing (DON) confirmed that the facility's expectation was for any medication with a broken seal to be discarded and that it was unacceptable to keep pills in opened blister packs. The DON also stated that nurses were responsible for checking blister packs for broken seals during shift changes, and that the ADON and DON were to check carts weekly, with the pharmacy consultant auditing monthly. Facility policy required all drugs to be stored in a safe, secure, and orderly manner, and not to use deteriorated drugs, but these procedures were not adhered to in the cases observed.