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.
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.
Blood glucose strip vials in a medication cart were found without open dates. An LPN confirmed the omission and stated the strips depreciate after opening, while the DON and other LPNs stated the strips should be dated when opened because exposure to air can degrade them and lead to false blood sugar readings.
Expired and improperly dated medications were found in one medication room during an observation with the ADON. Items included expired povidone-iodine swab sticks, mineral oil enemas, Prostate, and fiber laxative, plus a tuberculin vial in the refrigerator without an open date or expiration date. The ADON also confirmed a resident’s Levemir FlexPen had passed the manufacturer expiration date, and the DON stated medications should not be expired in the medication room or medication carts.
The facility failed to keep medication carts locked and attended as required by policy. The DON observed an unlocked, unattended cart on C-hall, and an observation on A hall showed a CMA leaving an unlocked med cart while she went to check on a resident before giving a BP med; the CMA later apologized for not locking the cart.
Expired drugs were found in one medication room and two medication carts after surveyors observed a Dulcolax suppository, hemorrhoidal suppositories, Bisacodyl stimulant laxative, and a resident-specific nitroglycerin tablet past their expiration dates. An LPN and the unit manager confirmed the expired items, and the Administrator and DON stated the charge nurse was expected to check carts and medication rooms weekly for expiration dates.
An unlocked and unattended medication cart was found on one hall, and multiple medications on another cart had no open dates, including insulin vials, an insulin pen, eye drops, and blood sugar strips. Staff confirmed the cart should have been locked and that open dates were required on insulin, ophthalmic medications, and strips. The affected residents included two residents with DM receiving insulin, two residents with eye drop orders, and one resident with an insulin pen order.
An unlocked medication cart on the G Hall Corridor was observed unattended and out of direct sight of an RN for three to five minutes. RN DD confirmed the cart should have been locked, and CMA EE stated she stepped away briefly to get ice. The facility policy states medication supplies are to be stored securely and accessible only to authorized personnel.
Unsecured medication cart and unlabeled glucometer strips: One medication cart was observed unlocked and unattended in the hall, and one bottle of blood sugar strips in a cart drawer had no open date. The UM, an LPN, and the DON all confirmed that carts should be locked when not in use and that glucometer strips require an open date.
Unsecured medication storage and expired medications were found in multiple carts and medication rooms. An LPN wound care cart and an RN medication cart were observed unlocked and unattended or out of direct sight during med pass, and staff confirmed the carts should have been locked. Surveyors also found numerous expired wound care products, oral meds, suppositories, ear drops, nicotine patches, and central supply items, along with insulin and methotrexate products missing open or expiration dates; staff acknowledged these items should have been removed or labeled.
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