HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to medication storage for 1 of 10 patients (Patient #1).

Findings include:

1. Facility policy titled "Medication Administration - Bar Code Med Scanning", PolicyStat ID 17595117, last revised on 3/2025 indicated the following: III. Procedure: 3. Do not remove medications for more than one patient at a time. 4. Take medication to the patient and administer immediately, do not store them in other locations.

2. During a phone interview with N6 on 6/26/25 at 2:40 p.m., N6 (Registered Nurse/Assistant Nurse Manager) indicated that in the early afternoon on 6/4/25, A5 (Director of Nursing Services/Facility #2's Heart Institute) had informed (him/her) that (Patient #1's) family had come to (him/her) about nitroglycerin being at (Patient #1's) bedside. N6 indicated that (he/she) had gone into (Patient #1's) room and looked around the patient's room for the bottle of nitroglycerin. N6 indicated that (he/she) had found a bottle of nitroglycerin located on the counter tucked beneath the sharps container, which was a difficult place to see the medication. N6 indicated that nurses usually prep medications on the counter near the sink in the patients' room. N6 indicated that medication should be put back in the patient specific medication box and/or locked in secure area in the medication room.