Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored according to professional standards of practice, as observed during the Recertification Survey. On the 4th Floor Medication Room, nineteen Heparin lock flush syringes with expired dates were found in a drawer, indicating a lapse in removing expired medications from storage. Registered Nurse #2 acknowledged that medications should be used by their expiration date to maintain effectiveness. Additionally, in the 3rd Floor Medication Room, food items such as plastic containers of coffee and coffee creamer were improperly stored next to intravenous fluid bags inside a cabinet. Both Registered Nurse #3 and the Director of Nursing confirmed that food should not be stored in the Medication Room, highlighting a breach in the facility's policy on Medication Storage and Handling.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - All expired medication (19 [MEDICATION NAME] lock flush syringes) were removed and discarded from Unit 3 (4th floor) medication room. - All food items were removed from Unit 2 (3rd floor) medication room. - RN #3 and RN #4 were re-educated on the Medication Labeling / Storage policy and procedure. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - All Unit RN Managers will do daily rounds to ensure all medications rooms, drawers and cabinets are free from expired Medication and food. - Review of the Medication Storage and Handling Policy was done on 12/13/24. The policies align with the current standards and professional practice and regulatory guidelines. No modifications made. - All Nurses will be re-educated on the policy. - The Pharmacy Consultant will audit unit medication carts when onsite monthly for expired medications. Quality Assurance Monitoring: - The Director of Nursing developed a tool to audit all medication rooms and medication carts. - Audits will be performed by the Director of Nursing/designee. - Audits will be performed on all Medication Carts and Medication Rooms, bi-weekly for 3 months, then monthly thereafter, until 95% accuracy is achieved. - The Director of Nursing will maintain a list of negative findings and any corrective actions taken including but not limited to immediate reporting to the Administrator/designee, re-education of involved staff and progressive disciplinary actions. - Audit findings will be reviewed and presented to the QAPI Committee at least quarterly for needed revisions in the action plan, and improvement of our delivery and resident outcomes. - The lesson plan for this plan of correction will be included in the facility’s orientation and annual training of all Nurses. Responsible Party: Director of Nursing