Improper Storage of Discontinued Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were securely stored in accordance with State and Federal Laws. During a standard survey, it was observed that two full boxes containing discontinued prescription medications for 22 residents were located in an unsecured first-floor conference room. These medications included insulin pens, inhalers, antipsychotic injectables, antibiotics, antidepressants, anxiolytics, anticonvulsants, diuretics, corticosteroids, antihypertensives, and vitamin supplements. The boxes were unlabeled, unsealed, and easily accessible, posing a risk of unauthorized access. Additionally, a full box of discontinued prescription medications for 32 residents was found in an open and unlocked Nurse Manager's office on the second floor. The medications included psychotropic drugs, antidepressants, antihypertensives, diuretics, and inhalers. The Nurse Manager admitted that the office door was not always locked, allowing potential access by residents. The Director of Nursing and other staff members were unaware of the proper storage procedures for discontinued medications, leading to their improper storage in unsecured locations. Interviews with the Director of Nursing, a pharmacist, and other staff members revealed a lack of awareness and adherence to the facility's medication storage policy. The Director of Nursing stated that discontinued medications should be kept in locked medication rooms or their office until pharmacy pickup. However, the medications were instead placed in unsecured areas like the conference room and Nurse Manager's office, which were accessible to staff, residents, and visitors. This failure to secure discontinued medications violated the facility's policy and posed a risk of unauthorized access and potential medication errors.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 All boxes of discontinued medications listed in the SOD were returned to the Pharmacy on 2/12/2025. All Licensed Nurses were counseled by the Education Nurse on 2/12/25 regarding appropriate medication storage in medication rooms & carts. All residents have the potential to be affected. All medications were collected from medication rooms, conference room, and all U.M Offices and promptly returned to the Pharmacy. DON/ADON/UM will educate nursing staff on proper return of discontinued medications. Discontinued medications should be stored in the locked medication rooms on each unit. The Pharmacy is to be notified of the need for discontinued meds pick up no more than biweekly. Education of LPN and RN nursing staff regarding Medication Storage with expected completion on or before 4/2/25. The Unit managers will spot audit medication rooms and carts on a daily basis to ensure appropriate medication storage. Any issues noted will be addressed. Weekly Medication Room audits will be conducted x 8 weeks by ADON/DON/UM to ensure expired medications are returned to the Pharmacy timely. Audits will ensure that discontinued medications are not stored in unlocked areas including conference, medication rooms, and UM offices. All findings will be reported to the QAPI Committee for review and comment. The DON will be responsible for the correction and monitoring.