Unsecured Probiotic Medication Stored on Top of Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure medications were secured and stored properly in locked compartments. During a medication pass observation with an LPN, a gray basin covered with a white towel was seen on top of the medication cart. The LPN removed a bottle of lactobacillus acidophilus (a probiotic) from the basin, took a capsule from the bottle, placed it in a medication cup, and administered it to a resident. The LPN stated that the basin contained applesauce, the probiotic, and Ensure, and that she kept the probiotic bottle in the basin on ice packs to keep it cold. She acknowledged that the probiotic was not locked in the medication cart because it needed to be kept on ice, and that the towel was used to keep it hidden from residents because “tempted eyes like to touch things.” Further observation and interviews confirmed that this was a standard practice at the facility. Another LPN explained that the facility had one locked medication room with refrigerators and a freezer for ice packs, and that medications requiring room temperature storage were kept in the medication room or cart, while refrigerated medications were kept in the medication refrigerator. She stated that lactobacillus, considered an OTC probiotic, was sometimes stored on top of the medication cart in a covered ice bucket with an ice pack and was not kept in locked storage, despite acknowledging that an unlocked medication could be accessed by a resident without a physician’s order. The DON confirmed that medication carts and the medication room were locked, but stated that probiotics such as lactobacillus, ordered by a physician and used as supplements, were stored on ice on top of the medication cart according to manufacturer’s directions and were not locked, and he did not believe there was any risk other than spoilage if manufacturer’s directions were not followed. Facility policy required that medication and treatment orders be consistent with principles of safe and effective order writing, but did not alter the observed practice of leaving the probiotic unsecured on the cart.
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