Failure to Secure and Properly Receive Medications, Including Controlled Substances
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and handled in accordance with federal, state, and local laws, as well as accepted professional standards. During an observation, a cardboard box containing medication blister packets, including controlled substances such as Alprazolam, Dronabinol, and Tramadol, was left unattended on the nurse's station countertop. A licensed vocational nurse (LVN) was later observed removing these medications from the box, which had been left unattended earlier in the morning. The LVN also left several medication blister packets unattended on the counter while stepping away from the nurse's station, during which time non-nursing staff and a resident were present in the area. Packing slips for the medications were not signed by the receiving nurse as required. Interviews with nursing leadership confirmed that pharmacy deliveries should be handed directly to a nurse and never left unattended at the nurse's station. The delivery person and the receiving nurse are both required to sign and date the delivery slip, but this procedure was not followed. The facility's policy also requires that a signed copy of the delivery receipt be returned to the pharmacy and retained for reconciliation, which was not done in this instance.