An LPN left Medication Cart 1 unlocked and unattended while preparing medications, then confirmed the cart had been left unsecured. Facility policy required drugs and biologicals to be stored in locked compartments with access limited to authorized personnel, and the DON confirmed medication carts should be locked when unattended.
Expired Medications and Supplies in Medication Cart: An LPN and surveyors found an ondansetron tablet for a resident, along with skin closures and IV needles, stored in a medication cart even though the items were expired. The resident had diagnoses including HTN, GERD, and low back pain, and had an active PRN order for ondansetron, but the MAR showed the medication had not been administered during the review period.
Undated insulin pens were found in a medication cart for two residents with DM. One resident had an order for Insulin Glargine at bedtime, and the other had an order for Semglee at bedtime. An LPN confirmed both pens were not dated when opened and were stored and available for resident use, and the DON later confirmed the same finding.
Expired UTI Stat supplements, blood collection tubes, and liquid antacid were found stored in the [NAME] House med room and available for resident use. An LPN confirmed the items were expired, and the DON confirmed they should have been discarded and not available for use.
Unsecured Medication and Treatment Carts: An LPN left the North Hall med cart unlocked and unattended while sitting out of sight of it, and later another LPN used an unlocked, unattended treatment cart behind the nurse's desk to obtain wound care supplies for a resident with cerebral palsy, malnutrition, and a stage 4 pressure ulcer. Facility policy required drugs and biologicals to be stored in locked compartments, and the DON stated med carts should be locked at all times and treatment carts were locked as well.
Expired medications were found on two medication carts, with an LPN confirming outdated clonidine, morphine sulfate, duloxetine, and hyoscyamine sulfate remained stored on the carts. The facility policy stated expired medications should not be available for use and should be removed from medication carts at or before expiration. Residents involved had diagnoses including HTN, kidney disease, dementia, Alzheimer’s disease, CHF, diabetes, depression, GERD, and osteoarthritis.
An LPN left a resident’s nebulizer treatment unattended after starting it, and a prescribed vaginal cream for another resident was observed unsecured on the bathroom counter instead of being kept in the med cart as ordered. The facility policy required medications and biologicals to be stored safely and securely and accessible only to authorized nursing staff.
Loose pills were found in a medication cart at a nursing station, including pills in the second and third drawers under bubble-pack cards. The facility policy required medication storage areas to be clean, organized, and free of clutter. The IP stated the loose pills should not have been in the cart, and the DON stated out-of-service medications should be stored in secured, specifically labeled locations until destroyed or returned to the pharmacy.
Medication cart security was not maintained for Cart 700. Facility policy required the cart to be locked when out of the medication nurse’s sight, but an RN walked away from the cart and later entered a resident room while leaving it unlocked and unattended. The RN confirmed the cart should have been locked, and the President of Clinical Operations confirmed carts should be locked when unattended.
Unsecured and unlabeled medications were found at a resident’s bedside and in a medication cart. A resident with multiple diagnoses, including HTN and delusional disorder, had several scheduled oral meds left unattended in a clear cup on the nightstand without a self-administration order or assessment, and an LPN identified the pills as the resident’s medications. In a separate observation, an LPN and the DON found prepared, unlabeled meds left in a med cart drawer instead of being administered or otherwise secured.
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