Improper Pre-Preparation and Storage of Medications by Nursing Staff
Penalty
Summary
Nursing staff failed to comply with facility policy and professional standards regarding the storage and preparation of medications. During an early morning observation, a registered nurse and an LPN were found to have pre-prepared and stacked clear medication cups containing both controlled and non-controlled drugs on and inside their medication carts. This practice was confirmed by both staff members, who acknowledged that medications for multiple residents were prepared in advance and left unattended, rather than being administered directly from secured storage at the time of medication pass. The facility's policy requires all drugs and biologicals to be stored in locked compartments and to remain under the direct observation of authorized personnel during medication administration. Among the pre-prepared medications, several cups contained controlled substances such as Clonazepam, Ativan, and Tylenol with Codeine, which had been signed out on the Controlled Drug Received/Record/Disposition Form. The staff involved stated that they resorted to this practice due to time constraints and resident behaviors, but acknowledged it was not in accordance with policy. The administrator confirmed that the pre-preparation and stacking of medication cups was not permitted and that the involved staff would not return.