Improper Medication Storage and Unsecured Medication Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications and biologicals, including insulin and oral medications, on multiple medication carts. During an initial tour, one upstairs medication cart was observed sitting in a hallway outside the nurse’s station, unlocked and unattended, while several staff members walked by before a staff member eventually locked it. When this cart was later inspected with an RN, multiple loose, unidentified pills were found in the bottom of the cart drawers, including tan, white, and green tablets; the RN identified two of the pills as Protonix and Eliquis. A second upstairs medication cart, observed with a QMA, contained an unopened and undated Novolog insulin pen for a specific resident in the top drawer, as well as an opened vial of Novolog for another resident that had been opened on 02/11/2026 and labeled to expire on 03/11/2026, but remained in use beyond that date. The drawers of this cart also contained crumbs and paper debris. The QMA stated that insulin was good for 28 days once opened. On the dementia unit, another medication cart observed with an LPN contained an unopened and undated Lantus insulin pen for a resident, along with several loose pills (round white pills, a round tan pill, and a half white pill) scattered in the drawers. The LPN reported she was unsure what the loose pills were or who was responsible for cleaning the medication carts, and indicated she attempted to clean the cart when she had time. Extended observation of the dementia unit medication cart showed it remained unlocked and unattended in a common area for over 20 minutes while residents, staff, a housekeeper, and the Maintenance Director passed by or worked near it, and the nurse remained behind a locked nurse’s station door with her back to the cart. Additionally, during a medication pass, a QMA prepared medications for a resident and left another medication cart unlocked in the hallway while going into the resident’s room, where the cart was not visible and no staff or residents were present in the hallway. In interviews, an LPN and the DON both stated that medication carts should be locked when the nurse is not present. Facility policy on medication storage required medications and biologicals to be stored safely, securely, and properly, with medication rooms, carts, and supplies locked or attended by authorized personnel, and storage areas kept clean and free of clutter. Manufacturer inserts for Novolog and Lantus, provided by the DON, described proper storage and expiration parameters for unopened insulin pens.
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