|§483.45(g) Labeling of Drugs and Biologicals|
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of six medication carts (Mauve Hall- memory care unit).
The facility policy entitled "Administering Medications," dated 1/16/20, indicated that the medication cart must be kept closed and locked when out of the nurse's view.
Observation on 1/14/20, at 3:53 p.m. revealed Registered Nurse (RN) Employee E1 administering medications from one of two medication carts (Mauve) parked in the hall on the Memory Gardens Unit. A second medication cart (Primrose) was noted to be unlocked. RN Employee E1 locked and left the Mauve medication cart unattended, walked down the hall to administer medications to a resident in their room and did not securely lock the Primrose medication cart which was left out of sight of RN Employee E1.
Further observation on 1/14/20, at 4:12 p.m. revealed that RN Employee E1 prepared medications for a resident from the Mauve medication cart, locked the cart, proceeded to the dining room to administer medications, and did not securely lock the Primrose medication cart which was left out of sight of RN Employee E1.
During an interview on 1/14/20, at 4:14 p.m. RN Employee E1 confirmed that he/she was administering medications out of both carts and that he/she had been into Primrose cart earlier in his/her shift and neglected to lock it, and that the medication cart should have been locked when out of his/her sight.
During an interview on 1/15/20, at 11:39 a.m. the Director of Memory Gardens confirmed that medication carts are to be locked when they are not in view of staff.
28. Pa. Code 201.18(b)(1) Management
28. Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(d)(1) Nursing services
| ||Plan of Correction - To be completed: 02/28/2020|
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Crawford County Care Center agrees with the allegations and citations listed on the statement of deficiencies. Crawford County Care Center maintains that the alleged deficiencies do not individually or collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. The plan of corrections shall operate as Crawford County Care Centers written credible evidence of compliance.
By submitting this plan of correction, Crawford County Care Center does not admit to the accuracy of the deficiencies. The plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Crawford County Care Center reserves all rights to raise possible contentions and defenses in any civil or criminal claim, action or proceeding.
No residents were affected by the medications carts being unlocked or unattended. The medication cart was locked after identification, without any adverse consequences. Employee 1 was educated immediately on the Medication Administration policy and procedure for storage of medications and securing the medication cart when left unattended.
All residents are at risk to be affected by this practice. All medications carts will be checked to validate they are locked and stored appropriately.
Licensed nursing staff will be educated on properly securing medication carts when unattended.
Random medication cart audits will be completed on various shifts daily for five days, weekly for three weeks and monthly for two months, then ongoing every month on all shifts during and after medication pass thereafter. Audit results will be reviewed by the Quality Assurance and Process Improvement Committee for further review and recommendation.