Unlocked Med Cart and Pre-Poured Narcotics During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to store medications in a safe and secure manner and to administer medications in accordance with professional standards and facility policy. Surveyors observed an unlocked medication cart labeled "100/300 Halls" left unattended in an open hallway in front of the nurses’ station. The Assistant Director of Nursing confirmed the cart was required to be locked when unattended. The facility’s Storage of Medication policy stated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and that all compartments containing drugs and biologicals, including carts, must be locked when not in use and not left unattended if open or otherwise accessible. The report also describes improper medication administration practices involving four residents. One resident had a diagnosis of epilepsy and an order for phenobarbital 32.4 mg once daily for seizure control, with a care plan intervention to administer seizure medications as ordered. Another resident had localization-related idiopathic epilepsy and epileptic seizures, with an order for phenobarbital 64.8 mg twice daily and a care plan addressing altered neurological status related to seizure disorder, including administering medications as ordered. A third resident had chronic cholecystitis, psychoactive substance abuse, muscle weakness, and difficulty walking, with an order for tramadol 50 mg every six hours as needed for pain and a care plan addressing altered comfort related to pain and functional limitations, with interventions to administer medications as ordered. A fourth resident had a diagnosis of opioid dependence in remission and an order for buprenorphine HCl-naloxone (Suboxone) 8-2 mg sublingually daily for a history of substance abuse, with a care plan identifying Suboxone therapy and interventions to administer medications as ordered. During a medication pass observation, surveyors saw four clear plastic medication cups, each labeled with a resident’s name and containing a single pill, sitting on top of the medication cart. The LPN identified the pills as phenobarbital for the first two residents, tramadol for the third, and Suboxone for the fourth. The LPN acknowledged she had pre-poured all of these narcotic or controlled medications at one time so she would not have to repeatedly access the locked narcotic drawer and stated she routinely prepared all narcotics before beginning her medication pass, believing this was acceptable because the cups were labeled. The facility’s Medication Administration policy required medications to be removed from their source immediately prior to administration and administered as ordered, with observation for resident consumption, and the DON confirmed medications were not to be pre-poured prior to administration.
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