Controlled substances were left unsecured in the DON’s office instead of being kept in locked storage. Two LPNs found the drawer seal broken and the drawer unlocked while trying to recover narcotics placed there per the former DON’s instruction. A maintenance employee, who was not authorized to handle medications, admitted removing the drugs, pouring cleaning solution over them, and discarding them in the dumpster. The facility could not verify that all of the medications were recovered.
An LPN left two medications in a cup at a resident’s bedside instead of ensuring they were administered and secured. The resident had seizures and moderate cognitive deficits, and the resident’s daughter later found the pills still sitting on the bedside table. The RN supervisor confirmed the medications were unattended in the room, and the LPN acknowledged leaving them behind after being called away to another resident.
An LPN left an opened Lantus insulin pen without an opening date on a medication cart, and another LPN found an unopened Levemir insulin vial and three Spikevax COVID-19 vaccine syringes available for use after their expiration dates in a medication refrigerator. The DON confirmed medications should be dated when opened and expired insulin and vaccines should be removed from use.
An LPN administered an expired liquid vitamin from a medication cart after failing to verify the expiration date, and on another cart, an LPN left two insulin-filled syringes unsecured on top of the cart while walking away to administer insulin to a resident. The DON confirmed that medications should be checked for expiration before administration and that insulin and other medications should never be left unattended and unsecured.
A resident with COPD and anxiety was allowed to self-administer an albuterol HFA inhaler, but the inhaler was left on his bedside table and accessible when he was not in the room. The resident said he kept it in his pocket or on the table for use when short of breath, and staff confirmed it should not have been left unattended because wandering residents could enter rooms and take medications not meant for them.
Expired and undated medications were found in an A Hall med room and med cart. An opened vial of Novolog insulin was kept beyond the 28-day period after opening, an Albuterol HFA inhaler was used past its printed expiration date, a bottle of chewable antacid tablets was expired, and several opened liquid medications and nasal spray lacked opening dates. An LPN confirmed the items were in use, and the DON stated nurses were responsible for monitoring expiration dates and labeling medications when opened.
Improper Storage of Controlled Medication in Refrigerator: An LPN observed 44 Lorazepam syringes for a resident stored on the center shelf of a medication refrigerator instead of in the locked controlled-substance box. The LPN stated the syringes would not fit in the locked drawer, and the DON confirmed they were not secured there even though they should have been. The resident had Anxiety Disorder and severe cognitive impairment with a BIMS score of 00.
Controlled substances were not stored as required when two of four medication carts contained removable narcotic storage boxes instead of permanently affixed compartments. An LPN on each wing confirmed the boxes could be removed, and the DON also verified the carts were not affixed. The pharmacist, Administrator, and an RN stated they were unaware the storage boxes were not permanently affixed.
Unlocked Medication Cart Left Unattended: Surveyors observed one of eight medication carts unlocked and unattended while an LPN was away from it. Facility policy required all drugs and biologicals to be stored in locked compartments, and the LPN confirmed he left his cart unlocked. He stated that leaving the cart unlocked and unattended could allow resident access to medications that could cause harm.
Medication was left unattended at the bedside for one resident, and a prescription bottle of Nystatin powder belonging to another resident was found at a different resident’s bedside. An LPN acknowledged leaving oral meds at the bedside despite knowing they should not be left unattended, and the DON confirmed the expectation was to observe the resident swallow the meds. The bedside Nystatin bottle was not from the facility pharmacy and there was no active order for it.
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