Failure to Secure Controlled Medications in Narcotic Wall Storage Unit
Penalty
Summary
The deficiency involves failure to ensure controlled medications were securely stored in a locked compartment as required by facility policy and professional standards. During observation of the 800 hall narcotic wall storage unit, surveyors found the outer door not properly secured and able to be opened completely, and the inner door, which also had a locking mechanism, was unlocked. The inner door’s lock had several rubber bands around the locking mechanism and one around the lock and top of the inner door, while multiple resident narcotic medications were stored inside with no staff present in the hallway. When the Administrator arrived and was informed of the unlocked controlled substance wall unit, they attempted to locate the nurse responsible for the medications. Shortly thereafter, a nurse approached the wall unit and stated they thought it was locked. The nurse attempted to engage the outer door lock, which was already in the locked position and therefore unable to close, then used a key to lock the outer door. When questioned about the inner door, the nurse attempted to use the same key but reported it did not work and believed the lock had recently been changed or fixed. The DON then attempted to secure the inner door with the same keys and confirmed there was no working key for that door. The nurse reported last accessing the narcotic wall unit at approximately 9:00 AM. Later, during the exit conference, the DON confirmed there were six controlled medication wall units in the facility and that no issues had been found with the others. A corporate nurse acknowledged prior awareness of the need for repair to that specific wall unit’s lock and that they had been working on having it fixed, and did not provide an explanation when asked why controlled medications had not been removed from that storage area despite knowing it was not locking properly. The facility’s policy states that only authorized licensed nursing and pharmacy personnel have access to controlled medications and that the medication nurse on duty maintains possession of the key to controlled medication storage areas.
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