Loose, Unlabeled Medications Found in Two Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications when multiple loose, unlabeled pills were found in two of four medication carts observed on Hall 300. During an observation of Medication Cart #2 with a nurse present, surveyors noted several loose tablets of various shapes, sizes, and colors in multiple drawers of the cart, including pink, yellow, brown, white, and orange tablets, some marked and some unmarked. These pills were not in original packaging and lacked required identifying information such as the resident’s name or prescribing information. When questioned, the nurse confirmed the presence of the loose tablets and was unable to explain why medications were stored without the minimum required labeling information. A similar observation of Medication Cart #1 on the same hall, conducted with a medication aide present, revealed additional loose, unlabeled tablets and a capsule of various colors and sizes in several drawers of that cart. The medication aide confirmed the presence of these loose medications and likewise could not explain why they were stored without required identifying information. In subsequent interviews, the Unit Manager stated that staff were expected to audit medication carts during shift change and report any loose medications, but could not explain why loose pills were present in both carts. The DON reported that medication carts were audited by Unit Managers and the pharmacist and stated that all loose pills should be disposed of, but was also unable to explain why loose tablets were found in the two medication carts during the survey.
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