An unlocked med cart on the 300 Hall was left unattended in the hallway and accessible to anyone passing through the area. RN stated he left the cart unlocked, even though it contained narcotic meds in a locked box and other resident meds in the drawers. The UM and DON stated all med carts are expected to remain locked and secured, and that the assigned nurse is responsible for keeping the cart secured.
A prescribed topical antibiotic was found sitting unattended on a resident’s dresser and readily accessible in the room. The resident was cognitively intact and had not been authorized to self-administer medications. The NP stated medications should not be left in resident rooms, and the DON stated the resident had no self-administer order and medications should be kept under lock and key.
Expired medications and supplies were found in multiple medication storage rooms, including lancets, blood collection tubes, hypodermic needles, Bluetooth glucose monitoring strips, IV catheters, and an IV start kit. Surveyors also found a multi-use vial of regular insulin in the refrigerator without an open date or required dating. An LPN and a CMA confirmed the items were expired or improperly labeled, and the DON stated medications should be labeled and dated according to policy.
Expired Diclofenac topical gel was found in a treatment cabinet, and an LPN confirmed it was expired and had no resident name on it. The ADON stated two residents had current PRN Diclofenac orders, but staff could not determine which resident the medication belonged to. The Administrator stated nurses are expected to check medication carts and treatment cabinets for expired meds.
An unlocked medication cart was observed on the 600 Unit with no staff present. CNA #8 confirmed the cart was unlocked, and the DON stated medication carts should be locked when not in the direct care of staff. The cart served 58 residents on the unit.
The facility failed to keep the medication and supply room locked and secured, and expired blood collection tubes were found in medical storage rooms. During observation, the west hall med room was unlocked, and multiple expired blood collection tubes were identified in the [NAME] Hall and East Hall storage areas; an ADON and two LPNs acknowledged the room should be locked and the expired tubes should have been discarded.
Surveyors found that a treatment cart containing drugs and biologicals on two units was left unlocked and unattended, with no staff present. An LPN confirmed the cart belonged to the treatment nurse, who was not on the unit at the time, and acknowledged that it was unlocked. A consultant nurse later stated that treatment carts are required to be locked when not in use.
Medication security and storage failures were observed when an unlocked narcotic box was found in a med cart, medications were pre-poured and left in the cart for future use, and a loose oral tablet was found on the floor in the 200-unit. An LPN, CMAs, ADON, and DON all stated medications and controlled substances should be secured, not pre-poured, and not left unattended or out of packaging.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Staff failed to keep medication and treatment carts locked and attended on three hallways, resulting in unsecured medications and supplies. A medication cart on one unit was observed unlocked and unattended outside a room, and an LPN confirmed it was her cart and that it should have been locked. Another medication cart on a different unit was also found unlocked and unattended, which a CNA confirmed. A treatment cart on a third unit was similarly observed unlocked and unattended outside a room, and an RN acknowledged it should have been locked before leaving the area. The DON stated that medication and treatment carts are expected to be locked at all times when not in use or when nurses are away from them.
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