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.
Unattended Nebulizer Treatment and Improper Equipment Cleaning: A resident with COPD, HF, and anxiety received a DuoNeb treatment while holding the mouthpiece in his mouth with no nurse present, even though the DON stated he had not been assessed to self-administer meds. After the treatment, an LPN wiped the mouthpiece with a paper towel and placed it in a bag with the nebulizer cup still attached, rather than separating, rinsing, and air-drying the parts as required by policy.
Surveyors found unsecured medications in a medication room and in two residents’ rooms. In the med room, lorazepam vials were stored in an unlocked box in the refrigerator, and staff stated the box should be locked and secured. Two cognitively intact residents also had unsecured bedside medications: one had arthritis gel and another had wound cleanser, while the DON stated resident meds should be kept in the med cart and wound cleanser stored in a cabinet or drawer.
Expired and undated OTC medications were found available for resident use in a medication cart and the Central Supply room. Surveyors observed expired Prilosec OTC, an opened and undated bottle of Cetirizine, and several expired items including Iron tablets, Aspirin, Cholest Off Plus, and Acid reducer tablets. An LPN UM, the SC, and the ADON all confirmed the medications were expired or undated and had not been removed from inventory or discarded.
Unsecured medications were found in resident rooms and a treatment cart was left unlocked and unattended. An LPN verified that a resident had potassium and hydrocodone at the bedside, and another resident’s room contained allergy relief eye drops on the nightstand without an order. Staff also left a treatment cart unlocked in the hallway during wound care, and the DON stated medications should be kept locked and controlled substances double locked.
Medication was left unattended during PEG administration when an LPN placed Valproic Acid Oral Solution on an over-bed table and went into the bathroom, leaving it out of sight more than once. The resident had a PEG tube, seizures, and severe cognitive impairment, and the facility policy required medications to remain under the direct observation of the person administering them.
A resident with severe cognitive impairment was found to have a bottle of topical pain relief roll-on and a bottle of oral rinse mouthwash left unsecured in their room, in violation of facility policy requiring medications to be stored in locked compartments. The DON confirmed that these medications should not have been accessible in the resident's room.
Surveyors found that opened insulin pens and an ophthalmic solution on a medication cart were not labeled with open dates as required by manufacturer guidelines and facility policy. One resident with Type 2 DM, chronic pain syndrome, and HTN had an opened Tresiba FlexTouch pen at room temperature labeled only with a 56-day discard instruction but no open date. Another resident with Type 2 DM, COPD, and HTN had an opened NovoLog pen at room temperature labeled only with a 28-day discard instruction and no open date. A third resident with glaucoma, major depressive disorder, and HTN had an opened latanoprost eye drop bottle labeled with a 42-day discard instruction but no open date. An LPN and the DON confirmed that these medications were not stored and labeled properly.
A medication cart was observed unlocked and unattended in a hallway, with no staff present. An LPN confirmed leaving the cart unsecured while attending to a resident in another room, contrary to facility policy requiring medication carts to be locked and attended by licensed staff.
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