Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to properly store refrigerated medication in one of the medication carts observed, specifically the B unit Short Hall medication cart. The facility's policy requires that medications needing refrigeration be stored in the refrigerator located in the drug room at the nurses' station. However, during an observation, it was found that the medication cart contained 12 insulin pens and one insulin multi-dose vial that were not dated. These included various types of insulin such as Novolog, Lantus, Humulin R, and Humalog, which require specific storage conditions to maintain their efficacy. During interviews, an LPN expressed uncertainty about why so many insulin pens were in the drawer instead of being stored in the refrigerator. The Director of Nursing confirmed that the medications should have been dated upon opening and that any extras not in use should have been stored in the refrigerator according to the facility's policy. This oversight indicates a failure to adhere to the established protocols for medication storage, potentially compromising the safety and effectiveness of the medications.
Plan Of Correction
The facility will ensure insulin is stored in a safe, secure and orderly manner in accordance with federal and state regulations and facility policies. The insulin pens identified during survey without dates were discarded and immediately replaced. The facility will complete a house audit on all five medication carts to make certain all insulin is stored and dated appropriately. The Director of nursing or Designee will re-educate all licensed nurses, including new hires and agency of the facility policy and proper storage and labeling of insulin. The Director of nursing or Designee will complete an audit three times a week for four weeks and once weekly for three months to ensure insulin pens are stored and dated as indicated. The results of the audit will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.