| 9298 |
ALPINE VILLAGE RETIREMENT CENTER |
285190 |
706 JAMES STREET |
VERDIGRE |
NE |
68783 |
2013-03-28 |
431 |
E |
0 |
1 |
UVQR11 |
LICENSURE REFERENCE NUMBER 175 NAC 12-006.121 Based on observations, staff interviews and record review; the facility failed to assure medications were stored and secured at all times in accordance with facility policy and to prevent access from unauthorized persons. Observations revealed unlocked medication carts were not under direct observation of the persons administering the medications and medications were left unsecured during the medication pass. This had the potential to affect 13 residents (Resident 15, 1, 12, 23, 26, 52, 68, 67, 28, 20, 13, 22 and 5) identified as mobile, cognitively impaired and at risk for wandering. Facility census was 46. Findings are: A. Review of the facility policy for Storage of Medications (revised 4/07) included the following; Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. B. During observations on 3/25/13 from 11:35 AM to 11:48 AM, Registered Nurse (RN) - F and Licensed Practical Nurse (LPN) - E parked 2 medication carts in the dining room by the entrance of the chapel area as residents and staff were entering and exiting the room for the breakfast meal. RN-F and LPN-E left the medication carts unlocked, unattended and not under direct supervision as they crossed the dining room to administer medications to residents. C. On 3/26/13 from 7:56 AM to 8:15 AM, RN-N parked a medication cart in the dining room by the entrance of the chapel area as staff and residents were entering and exiting the area for the breakfast meal. The medication cart was unlocked and a drawer containing numerous medication cassettes was stored on the top of the medication cart. RN-N left the medication cart and medication cassettes unlocked, unattended and not in direct supervision while administering medications to the residents in the dining room. D. Interview with RN-N on 3/26/13 at 9:00 AM revealed usual practice was to leave the medication cart unlocked when staff were passing medications in the dining room. E. On 3/26/13 from 11:57 AM until 12:07 PM, Medication Assistant (MA) I parked a medication cart in the dining room by the entrance of the chapel as staff and residents were entering and exiting the area for the noon meal. MA-I placed a box containing Resident 5's medication cassettes on top of the medication cart. The medication cart was unlocked. MA-I proceeded to walk across the dining room to the kitchen door which left the medication cart and Resident 5's medication box unattended and not under direct supervision. (Surveyor ) F. During an interview on 3/27/13 from 9:00 AM to 9:15 AM, the Director of Nursing confirmed staff should have followed facility policy regarding medication storage. In addition, the following residents were identified as cognitively impaired, mobile and at risk for wandering; Residents 51, 5, 22, 13, 20, 28, 67, 68, 52, 26, 23, 12 and 1. |
2016-09-01 |