Failure to Securely Store Medications Pending Pharmacy Return
Penalty
Summary
The facility failed to ensure that drugs and biologicals pending return to the pharmacy were stored securely in accordance with federal, state, and local laws. Multiple observations revealed that medication blister packets were kept in open cardboard boxes on the floor of the DON's office, which was frequently left open and unsupervised. The medications were visible from the entrance, and at various times, the office was unattended while non-nursing staff, such as a housekeeper, were present. Both the DON and the Administrator acknowledged that the medications were not stored in a locked cabinet and that the office door was not consistently secured. Interviews with nursing staff indicated that the standard practice was to place medications pending return to the pharmacy in locked containers within the medication room. However, the DON admitted that she was unsure how often medications were returned for credit and that some medications had been stored in her office since she began working at the facility several months prior. The Administrator confirmed that medications should not be left in the DON's office unless the door is locked, and that the proper procedure is to use locked containers in the medication room. Review of facility documentation showed that the last pharmacy pick-up slip was dated several months prior, and the Medication Return Logs indicated that medications had been pending return for an extended period. The facility's policy required that medications be securely stored and segregated until picked up by the pharmacy, but this was not followed. The failure to store medications securely in locked compartments as required was confirmed by both staff interviews and direct observation.