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.
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.
Surveyors found that a treatment cart and a medication cart on the 300 unit were left unlocked and unattended, with access to wound care supplies, scissors, topical creams, multiple oral medications (including Buspirone, Glipizide, Mirtazapine, Venlafaxine, Carbamazepine, Gabapentin, Colace), eye drops, and lancets. An LPN responsible for the carts confirmed they were open and acknowledged they should be locked when not in use, and the DON stated that medication and treatment carts are expected to remain locked and attended to prevent resident access and potential injury.
An unlocked medication cart on North Hall was observed in the hall with no staff present and medications stored in the unlocked drawers. The ADON confirmed the cart contained resident medications and that staff were expected to keep it locked when unattended.
Surveyors identified that a medication cart at the nurse’s station was left unlocked and unattended, contrary to facility expectations that carts remain locked when not in use, as confirmed by an RN and the DON. In addition, review of medication room refrigerator logs and direct observation showed temperatures repeatedly above the acceptable 36–46°F range, including readings of 48–65°F on several logged days and 50°F on the day of observation. A CMA and the DON both acknowledged the required temperature parameters and confirmed that the documented and observed temperatures were too high, creating a risk that medications stored there could become ineffective and unusable.
Surveyors found an expired vial of Naloxone 0.4 mg/mL PRN injection stored in the medication refrigerator during an observation of the medication storage room. The DON confirmed the medication was expired and should have been removed and placed in the designated pharmacy return or destruction area. Review of the facility’s Medication Storage and Expiration policy showed staff are required to regularly audit medication storage areas and remove expired medications, but this process was not followed for the Naloxone, creating a potential issue for any resident needing emergency opioid overdose reversal.
Surveyors found that the vaccine refrigerator temperature logs in the medication storage room were not completed on numerous dates across both day and night shifts, with large gaps in documentation over many months. An LPN acknowledged that the vaccine fridge temperature log was not being done routinely, despite nurses being responsible for all temperature logs. The DON confirmed that refrigerator temperatures were expected to be checked once per shift and recorded on the log, but this monitoring and documentation did not consistently occur.
Surveyors found that medications for a resident, including Pravastatin, Methocarbamol, and Buspirone, were left unattended on top of a medication cart without staff present, and both the ADON and a CMA acknowledged that these medications should not have been left unsecured. In a separate observation of medication storage rooms, lancets had been removed from their original packaging and stored loosely in a large, unlabeled bin without expiration dates, and the DON confirmed that this was how new lancet shipments were routinely handled and that this practice was unacceptable.
Surveyors found that a medication cart on the 400 hall was left unlocked and unattended near the nurse’s station, despite an LPN acknowledging it should always be locked. They also observed multiple expired respiratory medications, including a Breyna inhaler and ipratropium/albuterol inhalation solutions, stored in the treatment and medication carts for several residents. Staff interviews confirmed that nurses are expected to check for expired medications daily and each shift and to remove them from the carts, but these practices were not followed.
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