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F0761
D

Improper Storage of Medications and Biologicals

Rochester, New York Survey Completed on 01-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper storage of drugs and biologicals in accordance with State and Federal Laws, as observed during the Recertification Survey. Specifically, multiple medication carts contained insulin pens that were labeled by the pharmacy to be refrigerated until opened, yet they were found unopened and stored in the medication carts. Additionally, a vial of insulin was stored in a medication cart without being opened. These observations were made on Unit Three medication carts North and South, and Unit Two medication cart North. Licensed Practical Nurses acknowledged the improper storage and labeling of these medications during interviews. Further deficiencies were noted with the discovery of two used nicotine patches stuck to the shower room wall, dated from previous months. An opened vial of insulin with a needle attached was also found on a resident's bedside stand, which the resident attributed to a nurse's oversight. Licensed Practical Nurse Manager stated that medications requiring refrigeration should be stored accordingly and dated once opened, and that used patches should be discarded in sharps containers. The manager also indicated that cart audits should include checks for proper storage and labeling, and that staff should seek managerial advice for any improperly stored medications.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Insulin pen was removed from resident #70 room. All unopened insulin pens were removed from all med carts and placed in the refrigerator. Used nicotine patches were removed from the shower walls. Nurses will be educated by the unit managers regarding appropriate medication storage in medication rooms & carts. 2. All residents have the potential to be affected. The unit managers will spot audit medication rooms and carts on a daily basis to ensure appropriate medication storage. Any issues noted will be addressed. Unit managers will also spot audit shower rooms to ensure appropriate discard of the patches. 3. DON/Nursing administration will educate nursing staff on proper discard of nicotine patches. Education of LPN and RN nursing staff regarding C-MED-3 Medication Storage with expected completion on or before 3/3/25. 4. Weekly cart audit x4 weeks by DON/Nursing Administration to ensure drugs/biologicals used are labeled following currently accepted professional principles and the expiration date when applicable. Monthly audit x2 months or until the deficient practice is no longer identified; continue with random audits as needed to ensure continued compliance. Weekly shower room audits x 4, bi-weekly x 2 then monthly until the deficient practice is no longer identified. All findings will be reported to the QAPI Committee for review and comment. The DON will be responsible for the correction and monitoring.

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