Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications and biologicals on one of its nursing units, Station III, and for a specific resident, Resident 29. During an observation, a medication cart was found unlocked and unattended in a busy area of the nursing station, making it accessible to non-licensed staff, visitors, and other residents. This situation persisted for several minutes until it was confirmed by a licensed practical nurse. Such inattention to securing medications poses a risk of unauthorized access and potential misuse. Additionally, during a medication administration observation, a licensed practical nurse allowed Resident 29 to self-administer eye drops that were improperly labeled and stored. The eye drops were kept in a zippered pouch with other personal items, had a label that was rubbing off, and were not marked with the resident's name or administration details. The eye drops were also expired, and the resident required assistance to open the bottle. The nurse only realized the eye drops were expired after being informed by the surveyor. These findings were acknowledged by the facility's Administrator and Director of Nursing.
Plan Of Correction
1. Medication cart was locked at the time of the finding. Resident 29 eye drops (expired) were discarded and obtained new. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate nursing staff on labeling and storage of drugs and biologicals. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that medication carts are locked, and medications are appropriately stored. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.