Failure to Label Insulin Vial and Secure Self-Administered Medications
Penalty
Summary
The facility failed to properly label a multi-dose insulin vial and ensure the secure storage of medications for self-administration. During an observation, it was noted that a medication cart contained an opened, undated multi-dose Lantus insulin vial, which should have been labeled with the date it was opened to ensure timely disposal according to the manufacturer's instructions. A Licensed Practical Nurse (LPN) confirmed that the vials should be dated upon opening to prevent usage past expiration. Additionally, the facility did not secure medications for a resident who was permitted to self-administer. The resident's room contained a plastic storage bin with multiple medications left unsecured on a bedside tray table throughout the day. Interviews with LPNs revealed that the medications were left in the resident's room from morning until evening, contrary to the facility's policy that requires medications to be stored securely when not in use.
Plan Of Correction
Facility has done a full sweep to identify if any other residents have been impacted by the concern. No other residents were impacted. All other medication carts in the facility were reviewed by director of nursing or RN supervisor to determine no other inappropriate labeling or lack thereof had occurred. Inter-disciplinary team (IDT) reviewed the patient's care plan as well as physician orders with resident. Resident R22 understands there is a safety risk for other residents for leaving meds unattended in the room and is agreeable to keeping medications secured in the medication cart outside of medication administration times. Resident requests at the time of the medication needing given that medications be brought to bed-side, then R22 will prepare medications and take them supervised with nurse. The medications will be locked again and secured in med cart. R22 expresses the safety factor and is willing to participate. Nursing Staff have been educated on the new process in regard to this resident. Care plan and orders have been updated. Education was also provided to nursing staff on labeling vials. DON or designee will audit that this new process is happening 3 times a week for 4 weeks and then weekly for 6 weeks. Audits will be completed on multi-dose labeling and audited 3 times weekly for 6 weeks and once weekly for one month. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.