Unlocked Med Cart and Improper Narcotic Handling and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored and controlled in accordance with its own policies and accepted professional standards. During an observation, the B hall medication cart was found positioned on the side of the nursing station facing the hallway and left unlocked, while the assigned LVN was seated at the nurses’ station and not in view of the cart. The LVN acknowledged that the cart was unlocked and stated it should not be left in that condition. The facility’s written policy required that compartments containing medications and biologicals, including carts, be locked when not in use and not left unattended if open or otherwise available to others. The surveyor’s review of records for one resident showed an active order for hydrocodone/acetaminophen 7.5-325 mg, to be given every six hours as needed for pain, with the last administration documented on the MAR as occurring that afternoon. When the LVN and an RN later counted the narcotic medications in the B hall cart, the narcotic count sheet for this resident’s hydrocodone/acetaminophen indicated 17 tablets remaining, but the blister package contained only 16 tablets. The narcotic log showed the LVN had last signed out the medication the previous day, even though the LVN stated he had administered a dose that day and had forgotten to document it on the narcotic sheet. The LVN stated that the narcotic log needed to be completed at the time of dispensing to show who had given the medication. During the same narcotic count, the surveyor observed another resident’s blister pack of hydrocodone/acetaminophen 5-325 mg with a broken seal over one of the pills, although the pill remained in the package. The RN asked the LVN if tape could be placed over the package, and the LVN responded that the pill should be discarded. Both then decided to discard the pill. The RN initially dispensed a pill from a different resident’s blister pack of an unknown medication to discard, and the surveyor pointed out that the patient and medication did not match the observed blister pack. The RN and LVN then located and discarded the correct pill from the broken blister pack. The LVN later stated that any blister packs with a hole and the medication still inside should be discarded because they could have been tampered with or might not be the correct medication. The facility’s policies required controlled substances to be securely stored, properly documented, and any broken blister packs to be wasted with two staff as witnesses.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.