Failure to Secure Medication Carts and Ensure Proper Drug Storage
Penalty
Summary
Surveyors observed that multiple medication carts (MC #1, MC #2, MC #3, MC #5, and OFMC #4) were not properly secured and were left unlocked or with drawers not fully closed, making medications accessible to unauthorized individuals. Specific observations included a medication cart with an unlocked bottom drawer containing various medications and a reconciliation binder, as well as carts that appeared locked but could be easily opened by manipulating the locking mechanism. Some carts had prescription and over-the-counter medications belonging to residents, and one cart contained medications for a resident who was no longer at the facility. Interviews with staff revealed that medication carts were expected to be locked at all times when not in use, and only authorized personnel should have access. However, staff admitted to overlooking proper locking procedures, such as not ensuring drawers were fully closed before locking or not reporting malfunctioning locks. The Director of Nursing (DON) and other staff acknowledged that some carts had ongoing mechanical issues, particularly with battery-powered locks that could be disrupted if the carts were bumped against walls, causing the locking mechanism to fail. Further interviews indicated that staff were responsible for checking and maintaining the security of medication carts, including replacing or adjusting batteries as needed. Despite this, some staff were unaware of or did not report issues with the locking mechanisms, and at least one cart was found to contain medications for a discharged resident. The facility's policy required all medications to be stored in locked compartments with access limited to authorized personnel, but these procedures were not consistently followed, resulting in unsecured medications.