Failure to Label Opened Medications
Penalty
Summary
The facility failed to comply with the labeling requirements for multi-dose medication containers, as observed in one of the four medication carts inspected. Specifically, the First-Floor Southeast medication cart contained several inhalers that were opened but not labeled with the date they were opened, contrary to the facility's policy and manufacturer's instructions. The medications involved included fluticasone propion-salmeterol inhalers for Residents 32 and 135, umeclidinium-vilanterol inhaler for Resident 48, and fluticasone-umeclidinium-vilanterol inhaler for Resident 95. These medications have specific expiration guidelines once opened, which were not adhered to, as the opened dates were not recorded. During an interview, LPN 10 confirmed the oversight, acknowledging that the inhalers for the residents mentioned were indeed opened and not dated as required. The facility's policy, dated December 30, 2024, mandates that staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. This deficiency was identified based on a review of facility policies, manufacturer's instructions, clinical records, and direct observations.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #32, Resident #135, Resident #48 and Resident #95 undated medications were discarded at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit med carts to ensure that resident inhalers are dated properly. To prevent a future occurrence, the Director of Nursing/designee provided education to licensed nursing staff on the storage and expiration dating of medications and biologicals policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure that multi-dose vials are being dated properly. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.