Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several deficiencies observed during a survey. In the B-wing medication cart, multi-dose containers of inhalers for a resident were not labeled with the date they were opened, contrary to the manufacturer's instructions. Additionally, an insulin pen for another resident, which was no longer prescribed, was not discarded as required. These lapses were confirmed by a Licensed Practical Nurse during the survey. Further deficiencies were noted in the medication room and C-wing medication cart. The medication refrigerator's temperature was not consistently monitored and documented on the night shift, with only six recorded checks over a 17-day period. This was confirmed by a Registered Nurse. Additionally, loose medications were found in the C-wing medication cart, indicating improper securing of medications. These findings were corroborated by interviews with nursing staff and the Assistant Director of Nursing, who acknowledged the lapses in medication management and storage.
Plan Of Correction
1. Resident 2's inhaler was discarded due to being opened without being dated. Resident 63's insulin pen was discarded due to being discontinued. Medication room fridge temperature was checked and marked to be within appropriate level at time of review. Medication carts were checked and loose pills removed. 2. Medication carts were checked for inhalers and insulin pens for date and active order. Licensed Staff educated on dating open inhalers, discarding discontinued insulin pens, completing daily medication room fridge temperature and removing loose pills from medication carts. 3. Admissions Director, who is a licensed staff member, or designee will audit medication carts for undated inhalers or discontinued insulin pens weekly times four weeks and monthly times two months. Admissions Director or designee will audit medication carts to ensure no loose pills in the cart weekly times four weeks and monthly times two months. Assistant Director of Nursing or designee will audit medication room fridge temperature log for completion weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.