Loose, Unidentifiable Medications Found in Medication Cart
Penalty
Summary
A deficiency was identified when an audit and observation of medication cart #1 revealed two unidentifiable loose pills at the bottom of a drawer, under blister packs. Multiple interviews with LVNs confirmed that daily audits of medication carts are expected, but loose medications can occur when pills are accidentally dropped during administration. Staff acknowledged that such occurrences could result in medications not being administered as prescribed. One LVN described the loose pills as potentially an antipsychotic and melatonin. Another LVN stated that she had never verified medications received from the pharmacy, and described the process for handling controlled and reordered medications, indicating inconsistencies in medication management practices. The Director of Nursing (DON) confirmed that training on medication storage had been provided, but could not recall the last time she received it and was unsure of the specific policy regarding loose medications in carts. The DON and other staff stated that both the ADON and the pharmacist are responsible for monitoring medication carts through regular checks. The facility's policy requires that medications be stored safely, securely, and properly, and that any outdated, contaminated, or unidentifiable medications be immediately removed. Despite these policies, the presence of loose, unidentifiable pills in the medication cart indicated a failure to adhere to proper medication storage and labeling protocols.