Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in medication carts, as observed during a survey. On multiple occasions, surveyors found loose tablets in the drawers of medication carts across different halls, indicating a lack of adherence to the facility's medication storage policy. Specifically, on one occasion, two loose tablets were found in a medication cart drawer, and undated multi-use vials of Insulin Lispro and Lantus were observed. Additionally, loose vials of Heparin were improperly stored with insulins, which was acknowledged by an LPN who then corrected the storage. Further inspections revealed similar issues with loose tablets in other medication carts, with one LPN unsure about the frequency of cart cleaning, attributing the issue to the night shift. The facility's policies on medication storage and administration were reviewed, highlighting the requirement for medications to be stored in an orderly manner and for insulin vials to be dated upon opening. These observations indicate a failure to maintain medication storage areas in a clean, safe, and sanitary manner, as required by the facility's policies.
Plan Of Correction
F761- Label/Store Drugs and Biologicals What corrective action will be accomplished for those residents affected by the deficient practice? Destroy all loose pills in the drug buster that were found in D-Hall, B-Hall, A-Hall, G-Hall medication carts, the undated Lantus multi-dose vial and the undated Lispro. Place Heparin vial in the proper box labeled Heparin. Educated USFOIA (b) (6) assigned in A-hall, B-Hall, D-Hall, G-Hall medication carts on the Policy for Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug busters if found. Educated USO assigned in D-Hall cart the Policy on Medication Labeling of Multi-dose Vial. Given specific instructions on proper labeling expiration date of Lantus multi-dose vial once opened. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Unit Managers audited medication carts on their units and no further concerns were noted. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Nurse Educator began education on December 17, 2025 to RN/LPN's on staff of policy on Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug buster if found. Policy on Medication Labeling of Multi-dose Vial will be provided. Given specific instructions on proper labeling of multi-dose vials once opened. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by the Nursing Administration for loose pills in med carts, expiration labels on multi dose vials, and proper storage of Heparin Vials, weekly x4, monthly x3. The results of the audits will be reviewed at the monthly QAPI Committee chaired by the facility administrator.