Failure to Secure Medications and Lock Emergency Cart
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments as required by state and federal regulations. On the morning of the survey, a crash cart containing emergency supplies, equipment, and medications was found unlocked and unattended in a hallway outside the nurse's station. The drawers of the cart, which were accessible to passing residents, contained items such as scissors, syringes, tubing, and a first aid kit. Staff interviews confirmed that the crash cart should have been locked when not in use, and that its contents could be harmful if accessed by residents. Additionally, a tube of topical analgesic cream was found on the overbed table of a resident diagnosed with dementia, depression, and low back pain. The resident had a severe cognitive impairment and no physician order for the analgesic cream. There was no assessment for self-administration of medications, nor any documentation indicating the resident was competent to manage her own medications. Staff were unaware of the presence of the cream in the resident's room and acknowledged that it should have been stored securely and administered by nursing staff. Facility policy required that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. The policy also specified that medication rooms, carts, and supplies must be locked or attended by authorized staff. The observed failures to lock the crash cart and to prevent unauthorized medications from being present in a resident's room were in direct violation of these policies and regulatory requirements.