Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with professional principles. During an observation of medication administration on the 2nd floor, a Licensed Practical Nurse (LPN) left a medication cart unlocked and unattended while using the telephone at the nursing station. A medical ointment was also found on top of the cart, which the LPN admitted should have been stored in the treatment cart. The LPN acknowledged that the cart should have been locked when unattended, even if it was within sight. Additionally, a discrepancy was noted between the labeled orders and the Electronic Medication Administration Record (EMAR) during a medication administration observation with a Registered Nurse (RN). The RN administered 15 ml of Lactulose solution as documented in the EMAR, while the Lactulose bottle was labeled to administer 30 ml daily. The facility's policy on medication storage, dated April 2018, states that medications and biologicals should be stored safely, securely, and properly, accessible only to authorized personnel.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by the deficient practice. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? Alt medication carts were audited for medications left unattended, and carts left opened at the time, no other deficiencies were found at the time. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? All nurses will be educated on locking their medication carts, and ensuring no medications are left unattended. Random audits will be conducted weekly by the Pharmacy representative and/or designee. Any deficiency found will be addressed immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.