Medication and Biological Storage Deficiencies
Penalty
Summary
The facility failed to store medications and biologicals as required, as evidenced by several observations and staff interviews. Two of the twelve medication carts and three of the six medication rooms were found to have deficiencies. Specifically, treatments such as Bengay, Tender Calm skin protectant, and Zinc Oxide Ointment were improperly stored in a medication cart instead of a treatment cart. Additionally, a medication cup with a white pill was left unattended on top of a medication cart. Expired supplies, including a nasogastric feeding tube and a foley catheter, were found in the Fifth Main Medication Room, along with items improperly stored under the sink, such as a filled sharps container and cleaning supplies. Further observations revealed an outdated vial of Tuberculin in the Second Main Medication Room refrigerator and an unlabeled insulin glargine pen in the 2 Grove's medication room refrigerator. Staff interviews confirmed these findings, indicating a failure to adhere to proper storage protocols for medications and biologicals. The Director of Nursing acknowledged the facility's failure to meet the required standards for medication storage.
Plan Of Correction
1. Treatment creams were removed from 3 main north hall medication cart. Medication in cup was removed from top of Grove 1 back hall medication cart. Expired supplies were discarded from 5 main medication room. Items being stored under sink on 5 main were removed. Expired TB solution was removed from 2 main medication fridge and discarded. Unlabeled insulin pen in grove 2 medication fridge was discarded. 2. A house audit was done of medication carts and med rooms on all units to ensure no items were stored under sink, carts and med rooms were free of expired supplies and medication carts did not contain treatment creams. Medication room refrigerators were checked to ensure all unopened insulin pens were labeled and bagged. 3. Director of nursing or designee will educate licensed nursing staff on not storing items under sinks, proper storage of treatment supplies and medications, and discarding expired supplies. 4. Director of nursing or designee will audit 4 units (4 medication rooms and 8 medication carts) weekly for 2 weeks, then 2 units (2 medication rooms and 4 medication carts) weekly for 2 weeks, then 2 units (2 medication rooms and 4 medication carts) monthly for 2 months to ensure proper storage of drugs and biologicals and not items being stored under the sinks. Audit findings will be shared with QAPI committee.