An LPN was observed leaving an A-Hall med cart unsecured and unattended in a resident care area. The LPN confirmed the cart was unlocked and stated it should be locked immediately before walking away. The facility policy states meds and biologicals are to be stored safely and securely.
An unlocked medication cart was observed unattended in a hallway between resident rooms while an LPN was providing care to residents. The LPN later locked the cart and confirmed she had left it unlocked, and the DON stated that medication carts should always be locked when unattended.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
An unlocked treatment cart was observed in a resident-accessible area with the bottom drawer open, and an LPN confirmed it was unsecured while she could not see it. A separate medication cart had dirt-like substance in drawers and a loose, unlabeled packet of Zofran; the LPN was unsure who it belonged to. The facility policy and DHS interview confirmed medication carts were to remain locked when not in use and kept clean by nursing staff.
Medication carts and resident medications were left unsecured in the South Wing. One RN left two medication carts unlocked and unattended, and during a medication pass another RN placed a resident’s medications on top of the cart, locked the cart, and walked away to take the resident’s BP while the medications remained unsecured and visible in the mall area. The DON stated nurses were expected to lock the carts and secure medications when not in use.
Surveyors observed an unattended, unlocked medication cart with a medication bottle and a cup containing two loose pills left on top, with no nursing staff nearby, contrary to facility policy requiring medications to be under direct observation or locked during a med pass. An LPN reported leaving the medications on the cart while taking a resident to their room to check insulin, and both the DON and the Administrator confirmed that medications should not be left unattended and that once medications are removed, they are expected to be administered immediately.
Unlocked medication carts and an unsecured pill were observed on two hallways. An LPN left the 500 Hall cart unlocked while documenting, and a round pink pill was left on top of the cart after being found on the floor. Another LPN left the 200 Hall cart unlocked and unattended while in a resident’s room and stated she was unsure of the protocol for unlocked medication carts.
Incorrect Dating of Insulin Pens: An LPN and the IP found insulin pens on medication carts with handwritten open and discard dates that exceeded the 28-day beyond-use period in the manufacturer labeling. The pens included Lantus and Humalog, and the LPN was unable to verify the correct dating when asked. Facility policy required insulin vials or pens to be dated when opened, and the package inserts stated opened insulin should be discarded after 28 days.
Unlocked Medication and Treatment Carts: Springs Medication Cart #1, Springs Medication Cart #2, and Meadows Treatment Cart #1 were observed unlocked and unattended during survey observations. An LPN confirmed the treatment cart had been left open, and the facility policy required drug and biological storage compartments to be locked when not in use.
Expired medications were found in a medication room on the 100 Hall, including [NAME]-Vite, bisacodyl, acetaminophen, and zinc tablets with expired dates. An LPN confirmed the medications were expired and should not have been stored there, and the DON stated nurses were responsible for removing expired medications from the medication room.
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