Unlocked Med Carts and Improper Medication Handling
Penalty
Summary
The deficiency involves multiple failures to ensure medications and biologicals were securely stored and properly handled on three of four medication carts. On one evening, two unattended medication carts at the nurse’s station were found unlocked, and the surveyor was able to open both carts while staff and a resident were nearby. A medicine cup containing white powder was observed on top of one cart. A LVN on duty stated the carts belonged to another LVN who had left the facility for break about 20 minutes earlier, acknowledged that carts should be locked when not in use or out of sight, and admitted she had not realized the carts were left unlocked or that the cup with white powder was on top of the cart. She waited approximately 10 minutes before locking the carts. When the LVN who owned the carts returned from break, she confirmed the carts were the A/B Medication Aide Cart and the A/B Nurse Medication Cart and identified the white powder as antifungal powder, stating it should not have been left on top of the cart and that carts should be locked at all times when unattended. On another day, a red pill in a medication cup was observed on top of an unattended medication cart, with multiple residents and staff around it. A medication aide identified the cart as the C/D Medication Aide Medication Cart and stated she had dropped the pill earlier and placed it on top of the cart to dispose of it, but could not recall what medication it was. She acknowledged that medications to be disposed of should not be left on top of the cart and should instead be placed immediately in the biohazard box on the cart. The DON stated that medication carts should be locked when not within eyesight, medications should not be left on top of carts, and medications needing disposal should be destroyed immediately. The Administrator stated she expected staff to lock medication carts and not leave medications on top of them. The facility’s written policy on Medication Storage in the Facility required that medications and biologicals be stored safely, securely, and properly, with medication rooms, carts, and supplies locked or attended by authorized personnel.
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