Unsecured Medication Carts and Unattended Pre-Poured Medications
Penalty
Summary
Facility staff failed to properly secure and administer medications for all 112 residents listed on the census. Observations revealed that medication carts were left unlocked and unattended in hallways, providing unsupervised access to resident medications, including narcotic controlled substances. Additionally, staff were found to have pre-poured medications into unlidded cups and left them unattended on tables in resident care areas, with no licensed nurse present to supervise. These actions were in direct violation of the facility's medication administration policy, which requires medications to be prepared for one resident at a time, not to be pre-poured, and to remain secured and attended at all times. Interviews with staff confirmed these practices. A registered nurse acknowledged responsibility for keeping the medication cart locked and recognized that leaving it unsecured allowed unauthorized access to medications. A certified medication aide admitted to pre-pouring medications for multiple residents and leaving them unattended while assisting another resident, stating that this occurred once or twice a week. The aide also confirmed that the facility's policy prohibits pre-pouring and leaving medications unattended, and that staff are required to ask another qualified staff member to monitor medications if they must step away. The Director of Nursing confirmed that the facility does not permit pre-pouring medications or leaving them unsecured and unattended. She stated that only licensed individuals are responsible for medication administration and that certified nurse aides are not permitted to supervise medications. The DON acknowledged that leaving pre-poured medications unattended is unacceptable and creates significant risk, as staff would not know whose medications they were and residents or visitors could access them.
Removal Plan
- The identified CMA will not pass medications until further determination is made.
- The DON/designee checked all other medication carts to determine if there were any other pre-poured medications. No other instances of pre-poured medications were observed.
- The DON/designee checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- The DON/designee monitored residents on identified hall who received pre-poured medications, no concerns were identified. They were monitored for potential adverse medication reactions, such as a significant change in vital signs. No concerns were identified.
- Education was provided to all nurses and CMAs on-site regarding: Medications are to only be prepared for one resident at a time, using a 3-way-check (comparing the medication to the MAR and to the prescription label).
- No pre-poured medications are allowed.
- Medications are not to be left unsecured and unattended.
- Medication carts will be locked at all times when out of site or unattended.
- Nurses and CMAs that are coming in as scheduled, will receive education prior to passing any medications.
- Additional Nurses and CMAs that are not onsite will receive education via telephone and a signed acknowledgement of education will be obtained prior to their next working shift.
- Record review of new admissions audit to ensure accurate medication reconciliation, review and continuation of medications and treatments.
- Record review of staff signature sheets for checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- Interviews with nurses regarding in-services and on pre-pouring medication and leaving medications unsecure.
- Interview with the Administrator and DON regarding plan of removal, audits, and medication reconciliation processes.