Loose, Unlabeled Medications Found in Multiple Medication Carts
Penalty
Summary
Surveyors observed that multiple medication carts contained loose, unlabeled pills of various shapes and colors in their bottoms. Specifically, 15 loose pills were found in the Sycamore Hall cart, 20 in the Crystal Hall cart, and 5 in the Carousel Hall cart. Nursing staff, including RNs and LPNs, confirmed the presence of these loose pills and stated they were unable to identify the medications or determine to whom they were prescribed. These findings were corroborated through direct observation and staff interviews. A review of the facility's policy on medication storage indicated that drugs and biologicals should be kept in their original packaging, and nursing staff are responsible for maintaining proper storage. The failure to store medications in their original containers and the inability to identify the loose pills had the potential to affect 30 residents who received medications from the reviewed carts. The facility census at the time was 53.