Improper Storage of Medications in Riverside Medication Cart
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in one of its medication carts, specifically the Riverside medication cart. The facility's policy on the storage of medications, dated 11/5/24, requires that medications and biologicals be stored safely, securely, and properly, with orally administered medications kept separate from externally used medications and treatments. However, during an observation and interview on 1/7/25, it was found that the fourth drawer of the Riverside medication cart contained dividers labeled with room numbers and various creams, ointments, and gels, which were not stored separately from other medications. LPN Employee E1 confirmed that the facility did not have a separate treatment cart and referred to this drawer as the treatment drawer. Further inspection of the Riverside medication cart revealed additional storage issues. The fifth drawer contained an open box of paper tape, a container of antifungal powder, a box of vaginal cream mixed with seven oral Tussin liquid medication bottles, and a Ventolin inhaler and three nasal sprays commingled with dry dressing supplies. The bottom drawer contained a tube of antifungal cream, a tube of Voltaren gel, a tube of hydrocortisone cream, and two containers of Silvadene ointment, all mixed with respiratory treatment agents. LPN Employee E1 confirmed these observations, indicating a failure to adhere to the facility's medication storage policy.
Plan Of Correction
The Director of Nursing and designees organized the medication carts in all neighborhoods on the date of discovery to include a labeled drawer designated for topical medications. There were no known negative outcomes from the deficient practice of not properly storing biological medications separately from other medications. The Director of Nursing/ Designee will educate nursing staff on the proper storage of biological medications on medication carts/treatment carts by the compliance date. The Director of Nursing /Designee will conduct weekly audits for 4 weeks of medication carts/treatment carts to ensure biological items are stored properly in designated drawers. The results of audits will be submitted to the QAPI committee to determine if any negative trends exist that may require further intervention for improvement.