Non-compliance in Medication Storage and Labeling
Penalty
Summary
West Reading Skilled Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the labeling and storage of drugs and biologicals. The facility's policy required staff to label insulin vials and pens with the date they were first opened and to dispose of outdated, contaminated, discontinued, or deteriorated medications immediately. However, during a survey, it was observed that insulin pens on a medication cart for resident rooms 218 through 229 were not discarded after the recommended 28 days. Specifically, an insulin aspart pen opened on December 16, 2024, an insulin glargine pen opened on December 11, 2024, and a Semglee insulin pen opened on December 12, 2024, were still present. A licensed practical nurse confirmed that these pens should have been discarded. Additionally, the survey revealed that the medication storage room refrigerator on the third floor contained six single-dose pre-filled syringes of Prevnar 20 with an expiration date of December 2024. The Director of Nursing acknowledged that staff were responsible for labeling all medications with open and expiration dates and ensuring that expired or discontinued medications were removed from storage. These findings indicate a failure to adhere to the facility's medication storage policy, leading to the presence of expired medications in the facility.
Plan Of Correction
Insulin pens in the 2nd floor medication cart have been discarded. Expired Prevnar solution in 3rd floor medication refrigerator has been discarded. Medication carts have been inspected to ensure Insulin pens are labeled/dated and are current. Medication refrigerators have been inspected to ensure expired medications are discarded. Licensed nursing staff have been re-educated on F761 and the medication storage policy with attention to storage of insulin pens and discarding expired medications. DON/designee will audit medication carts and refrigerators at least weekly x4weeks then monthly x2months to ensure expired medications are discarded. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.