Medication Storage Deficiency in Nursing Unit
Penalty
Summary
The facility failed to properly store medications in one of its nursing units, specifically the Second Floor Nursing Unit. During an observation of a medication cart used for resident rooms 218 through 229, it was found that four insulin lispro pens, one insulin glargine pen, one Semglee insulin pen, and one Basaglar insulin pen were opened and not labeled with an open date. This was confirmed by an LPN who acknowledged that the insulin pens should have been labeled. Additionally, the medication storage room refrigerator contained an opened vial of Tubersol that was not labeled, despite being in a storage box labeled for discard by a specific date. Further inspection revealed three bottles of doxycycline labeled with a do-not-use-after date and a large container of glycerin suppositories labeled for a resident who had expired. The Director of Nursing confirmed that staff were required to label all medications with open and expiration dates and to remove all expired or discontinued medications from the medication cart and storage room refrigerator. These findings indicate a failure to adhere to the facility's policy on medication storage, potentially compromising medication safety and efficacy.
Plan Of Correction
1. The four insulin pens that were opened were not dated, the TB vaccine in the refrigerator opened and not dated, the three bottles of expired doxycycline, and outdated Glycerin suppositories were all removed and disposed of per policy. 2. An initial audit will be completed by the Director of Nursing/Designee on Medication refrigerator, carts and medication rooms to ensure medications are stored and labeled appropriately. 3. Licensed Nursing staff will be re-educated by the director of nursing or designee on the facility "Storage of medication" policy. 4. Unit Managers/RN Supervisors will conduct weekly random audits x 90 days med carts and med rooms to assure medications are stored and labeled appropriately. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.