Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper labeling and storage protocols for medications, as evidenced by observations and staff interviews. In Medication Storage Room Two, two tuberculin vials were found improperly managed; one vial was opened and undated, while the other was expired, having been opened on September 1, 2024, despite instructions to discard after 30 days. This was confirmed by a Registered Nurse, Employee E3, during an interview. Further deficiencies were noted on Medication Carts Four and Five. On Cart Five, five insulin vials, including Humalogs, Novalogs, and Lantus, were opened and undated. On Cart Four, two insulin vials, Novalog and Humalog, were opened on January 1, 2025, and exceeded the recommended 28-day usage period. These findings were confirmed by Employee E3 and Employee E5, a Licensed Practical Nurse, respectively. The facility's policy on medication storage, dated 2016, was not followed, leading to these deficiencies.
Plan Of Correction
1. All expired and/or undated medication that was identified was wasted. 2. Other medication storage areas were audited for compliance. 3. Nurses were in-serviced regarding labeling, dating and expired medications. 4. ADON or designee to complete random audits weekly on medication storage. Audits will be brought to monthly QAPI meeting x3 months, overseen by the Administrator.