Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications in two medication carts and one medication room, as observed during a survey. On the 2B Medication Cart, insulin pens for three residents were not stored in bags as required. Additionally, the Unit 1 Medication Cart was found unlocked and unattended, with a bottle of aspirin and a bottle of Vitamin D3 left on top of the cart. These observations were confirmed by an LPN, indicating a lapse in the facility's medication storage protocols. Further deficiencies were noted in the Unit 2 Medication Room, where several medications and supplies were found to be expired. These included Hemoccult Single Slides, COVID-19 Antigen Home Tests, Heparin Lock Flushes, and an Ace connector with Legacy Connection. The expiration of these items was confirmed by a registered nurse, and the overall failure to properly store medications was acknowledged by the Director of Nursing and the Nursing Home Administrator.
Plan Of Correction
The identified items from 2B and Unit 1 Medication Carts, Unit 2 Medication Room items were immediately addressed. R1, R54, and R81s insulin pens were immediately discarded. The DON/designee completed an audit of all medication carts and medications rooms to ensure medications are stored and labelled appropriately. There were no negative findings. To prevent this from recurring, the RDCS/designee educated licensed nursing staff on requirements of F761 and proper storage and labelling. To monitor and maintain ongoing compliance, the DON/designee will audit medication carts and medication room/refrigerators weekly x4 then monthly x2 to ensure medications are stored and labelled appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.