Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label medications and treatments on two of three medication carts, specifically the front hall and back hall medication carts. During an observation, it was noted that the front hall medication cart contained two dispensing bottles of nystatin powder, one tube of hydrocortisone cream, one vial of brimonidine eye drops, and one bottle of calcitonin nasal spray, all of which were not labeled with the date they were opened. Similarly, the back hall medication cart contained one tube of lidocaine and prilocaine (EMLA cream), one tube of lidocaine gel, one vial of polyvinyl eye drops, and one vial of Lantus insulin, also without the date of opening. These observations were confirmed by RN Employee E5, who acknowledged the improper storage and labeling. The deficiency was identified as a failure to prevent cross-contamination and ensure proper labeling of medications upon opening, as required by professional principles and facility policy. The lack of proper labeling and storage was observed during a survey, and the facility's non-compliance with the relevant Pennsylvania Code sections regarding pharmacy services, resident care policies, and nursing services was noted. The report does not mention any specific residents affected or any immediate consequences resulting from these deficiencies.
Plan Of Correction
The vial of eye drops, bottle of calcitonin nasal spray, polyvinyl eye drops and Lantus insulin were disposed of on 12/18/2024. The Nystatin powder and Hydrocortisone cream were placed in the treatment cart. On the day of the findings, the remaining medication cart was inspected and no other open/undated items were found, and no other treatments were found in the medication cart. DON and/or designee will educate RNs and LPNs on the need to store medications and treatments separately to prevent cross contamination, and the need to label medications such as but not limited to eye drops and calcitonin spray when opened. DON and/or designee will audit medication/treatment carts and med rooms to ensure medications and treatments are stored separately to prevent cross contamination, and that medications are labeled when opened. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results of the audits will be reported at the Quarterly QAA meeting.