Medication Administration and Storage Failures Across Multiple Medication Carts
Penalty
Summary
The deficiency involves multiple failures in medication administration and storage practices. One resident with mild cognitive impairment and disorientation was found with a small purple pill on the dresser near the bed; the resident did not know what the medication was and asked if it should be taken, and was prepared to take it with water. A registered nurse stated they had not left the medication at the bedside, acknowledged that nurses are supposed to ensure residents, especially those with cognitive impairments, swallow their medications, and could only speculate that the pill might be Levothyroxine scheduled earlier that morning before discarding it. This reflects a failure to ensure the resident took their medication as prescribed and that medications were not left at the bedside for a cognitively impaired resident. Surveyors also identified widespread problems with medication storage and labeling across three medication carts. On one cart serving 11 residents, multiple loose pills and capsules of various colors and shapes were found in several slots of a drawer, outside of their original packaging, and the LPN could not identify them; the LPN stated night shift nurses were supposed to clean the carts nightly. On a second cart serving 25 residents, loose white pills were found in multiple drawers outside their containers, and a bottle of Lorazepam oral solution ordered for a resident, labeled to be refrigerated at 36°F to 46°F, was found in the narcotic drawer instead of in the refrigerator; the LPN reported the bottle had been open since a prior date and was unsure how long it had been unrefrigerated. On a third cart serving 16 residents, there were more than 30 loose pills/capsules at the bottom and back of a drawer, with colored powder residue in the drawer slots, and multiple expired blister packs for one resident, including Hydroxyzine, Sennoside/Docusate Sodium, Gabapentin, Loperamide, and Senokot-S, all past their labeled expiration dates. These findings demonstrate failures to keep carts clean and sanitary, to maintain medications in original packaging, to discard expired medications, and to store medications per manufacturer recommendations, contrary to the facility’s own policies on administering and storing medications.
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