Failure to Secure and Properly Label Medications on Second Floor Carts
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were securely stored and properly labeled on the second floor. During an observation of medication cart #3 with a nurse, surveyors found an opened can of energy drink in a large drawer, a box of Dulcolax suppositories with an expiration date of 11/2025, and a bottle of redness-relieving eye drops in an opened box without a label identifying the intended patient. The nurse stated that expired medications should be discarded and that all medications in the cart should be labeled with a patient name. In a separate observation, the second-floor respiratory cart was found unlocked and not under direct observation of authorized staff; a second respiratory cart was also unlocked with a key left in the lock, and medications were accessible in the drawers. The respiratory therapist later confirmed that the respiratory carts contained breathing supplies, equipment, and medications. Additional observations showed a treatment cart on the second floor left unlocked and unattended outside a resident room, with the unit manager later approaching and locking the cart only after the surveyor’s presence. During a medication administration observation, an LPN retrieved medication from the narcotic box of the second-floor medication cart, where two clear medicine cups containing a cloudy gel-like substance were found lying sideways between narcotic blister packs. The LPN stated these cups were for a resident, that the substance had been taken from the treatment cart and placed into the cups, and then stored in the narcotic box, but the LPN was unsure of the medication’s name and had to look it up in the MAR. The DON later acknowledged that all respiratory, medication, and treatment carts must be locked, that storing medication in cups in this manner was unsanitary, and that medications without patient identifiers or labeling were not acceptable, in contrast to the facility’s written Medication Storage Policy requiring proper sanitation and security.
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