Failure to Secure and Properly Dispose of IV Medication
Penalty
Summary
A deficiency occurred when a nurse failed to properly store and secure an intravenous (IV) antibiotic medication prescribed for a male resident with a history of infection and inflammatory reaction due to an internal knee prosthesis. The resident was receiving IV medications, including vancomycin and ceftriaxone, for a knee infection and required enhanced barrier precautions and regular monitoring of his PICC line and dressing. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the day of the survey, the resident's PICC line medication, labeled as requiring refrigeration, was found left unattended on the exit door handle at the end of the resident hall, exposed to sunlight. The medication was not secured in a locked compartment as required by state and federal regulations. The nurse responsible for administering the medication admitted to leaving it on the door handle with the intention of destroying it later but forgot about it until notified by another staff member. The medication was subsequently destroyed by pouring it down the toilet after being retrieved by another nurse. Interviews with facility staff, including the LVN, MDS nurse, ADON, DON, and CNA, confirmed that the medication was not stored or discarded according to facility policy and regulatory requirements. Staff acknowledged that the medication should have been immediately secured and destroyed in the designated medication room container. The incident was recognized as a failure to follow proper medication storage and destruction protocols, which could have allowed unauthorized access to the medication.