Medication Labeling and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the presence of an undated 10 ml bottle of Systane eye drops in the first-floor medication cart. This oversight was confirmed by an LPN, who acknowledged that the eye drops should have been labeled with the date they were opened. Additionally, the facility did not discard expired medical supplies, as observed in the first-floor medication room, where 12 expired IV fluid bags were found. These included various bags of normal saline solution and dextrose solutions, which were confirmed to be expired by the same LPN, who mistakenly believed that the overnight staff was responsible for checking outdated supplies. Furthermore, the facility failed to properly document the administration of narcotic medications for two residents. Both residents, who were cognitively intact and experienced frequent pain, had physician's orders for Tramadol, a narcotic pain reliever, to be administered routinely and as needed. However, the controlled drug accountability records revealed that staff signed out routine doses of Tramadol from the as-needed medication card, which was confirmed by the Nursing Home Administrator. This mismanagement of narcotic medication documentation was identified for both residents, indicating a lapse in following proper procedures for controlled substances.
Plan Of Correction
1. The identified concern for the eye drop solution and intravenous, IV, fluids was immediately corrected. The identified concern R37 and R69 cannot be corrected. 2. The Director of Nursing or designee will audit all current medication rooms for outdated IV fluids and all medication carts for proper labeling and storage of eye drops. The Director of Nursing or designee will audit residents controlled opioid medication cards for accuracy of administration from the correct card. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for disposing of expired medications, labeling of open containers in medication cart, which includes monthly audits and opioid medication administrations to be given from the correct medication card. 4. The Director of Nursing or designee will audit 25% per unit of disposal of expired medications, labeling of open containers in medication carts and opioid administrations from the correct medication card. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.