Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to comply with regulations regarding the storage and labeling of drugs and biologicals. Specifically, controlled Schedule II-V medications were not stored in a separately locked, permanently affixed compartment as required. Instead, these medications were found in two separately locked containers attached to a removable shelf in the main medication room refrigerator. Additionally, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the appropriate discard date. Further deficiencies were observed in the A-Wing medication cart, where an open injector pen of Humalog insulin was found with an open date indicating it was expired. The pen had been opened on 12/25/24, and according to the manufacturer's guidelines, it should have been discarded after 28 days. These findings were confirmed by LPNs during interviews, highlighting lapses in the facility's adherence to proper medication storage and labeling protocols.
Plan Of Correction
The facility immediately disposed of the medication which was not dated upon notification of the concern. The facility immediately disposed of the expired Humalog insulin upon notification of the concern. The DON and ADON have audited all medication carts and the facility medication room to ensure that there were no expired or un-dated medications present. The facilities Maintenance Director permanently attached/affixed the removable shelf on the date that it was brought to the facilities' attention. The Director of Nursing and/or designee will educate the facilities nurses on the importance of properly dating medication, disposing of expired medication, and ensuring proper storage of controlled schedule II-V medications. An audit of all medication rooms and medication carts has been conducted to ensure that there are no undated or expired medications present, as well as ensuring that controlled substances are secured and stored properly. The Assistant Director of Nursing and/or designee will conduct a weekly audit of the med room refrigerator to ensure that controlled substances are secured/stored properly and one (1) med cart a week for 4 weeks to ensure that there are no undated and/or expired medications present and that the controlled substances are secured/stored properly within the medication cart(s). The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.