Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner, specifically in the 200-Hall medication storage room. During a review of the facility's policy on labeling medication containers, it was noted that stock medications should include necessary information such as the expiration date. Manufacturer's recommendations for Aplisol PPD, a solution used for tuberculosis testing, indicated that vials in use for more than 30 days should be discarded. However, an observation revealed an open vial of Aplisol in the medication storage room refrigerator without an opened date, making it impossible for staff to determine the discard date. This was confirmed by an LPN who acknowledged the lack of an opened date on the vial.
Plan Of Correction
It is the practice of this facility to ensure drugs and biologicals are stored properly. Immediately upon notification of unlabeled open PPD solution, open solution was discarded. All PPD inventory was checked for opened bottles with no open date. All licensed nursing staff to be educated by the DON/designee regarding the handling of the administration of PPD solution with emphasis on the importance of dating vials upon opening by 1/31/2024. Staff will be provided with clear reminders to date open PPD vials. The DON/designee to audit the medication refrigerators weekly x 4 weeks, monthly x 3 months, and quarterly x 2 quarters to assure ongoing compliance. This corrective action will be monitored through the facility Quality Assurance and Performance Improvement Program (QAPI). Findings will be submitted to the QAPI Committee for review and follow up.