Improper Medication Cart Security and Handling of Refused and Dropped Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications on the 100 Hall Bottom medication cart. During continuous observation of a day-shift nurse, the medication cart was found unlocked while the nurse was inside a resident’s room, and the nurse confirmed the cart should have been locked when unattended. The same nurse left three unused multiple-dose insulin syringes in a plastic bag on top of the unattended cart instead of securing them inside the cart. In addition, after a resident refused a prepared dose of digoxin 125 mcg, docusate 100 mg, two torsemide 20 mg tablets, and spironolactone 50 mg, the nurse placed the unlabeled medicine cup containing these medications in the top drawer of the cart with the intention of offering them again. Later, when administering finasteride 5 mg to another resident, the tablet was dropped on the floor; the nurse picked it up, placed it in a medicine cup, and stored it in the medication drawer beside another unlabeled cup of medications, stating she still needed to waste the dropped tablet. Further inspection of the same medication cart with the nurse revealed three additional unlabeled medication cups in the top right drawer: one cup with a single pill, one with five pills of various sizes, shapes, and colors, and one with three pills of various sizes, shapes, and colors. The nurse indicated that one of these cups contained medications left by a previous-shift nurse after a resident refused a 6:00 a.m. dose, and acknowledged that the medications should have been wasted rather than stored on the cart. The previous-shift nurse confirmed that a resident had refused medications and that they should not have been left on the cart. The DON and Administrator both stated they expected staff to keep medication carts locked when unattended, secure insulin syringes inside the cart, and dispose of refused or to-be-wasted medications rather than storing unlabeled medications in the cart.
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