Failure to Secure Medication Carts and Store Drugs in Locked Compartments
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments as required, as observed during medication storage inspections of four out of six medication carts. On multiple occasions, medication carts were found unattended and unlocked, with residents, visitors, and staff in close proximity. Specifically, Medication Cart #1 was left unlocked on hall 100 while the assigned nurse was on break, and the ADON confirmed that the cart should have been locked at all times when unattended. The nurse responsible for the cart acknowledged the oversight and stated that the cart contained various prescription and over-the-counter medications, including PRNs, insulin, blood pressure medications, pain and anxiety medications, antiepileptics, and OTC drugs. Although narcotics were said to be locked, the nurse admitted that they should have been secured under two locks, not one. Further observations revealed that Medication Carts #2, #3, and #4 were also left unlocked and unattended, with the keys placed on top of each cart and visible to anyone nearby. These carts contained a range of prescription medications, including heart, depression, diuretic, antinausea, diabetes, inhalation, anti-yeast, and OTC medications, as well as narcotics. At another time, Medication Cart #1 was again found unlocked, with several drawers open and no staff in sight. The cart contained a laptop, a cell phone, and keys hidden under the phone, along with a variety of prescription and OTC medications, insulin syringes, and lancets. Interviews with nursing staff and the acting DON confirmed that facility policy required medication carts to be locked at all times when unattended or out of direct sight of nurses. Staff acknowledged responsibility for ensuring the carts were secured and recognized that the failure to do so could result in medications being accessed by unauthorized individuals. The acting DON stated that the nurses had not followed the facility's medication storage policy, which mandates that all medications and biologicals be stored in locked compartments, with controlled substances separately locked.