Medication Storage and Self-Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as evidenced by the case of a resident who was observed to have multiple bottles of eye medications on their bedside table. The resident, who had diagnoses including Dry Eye Syndrome and Cataract, was seen self-administering expired Refresh Liquigel eye drops without a physician's order or an assessment to self-administer medications. The facility's policy required that medications be stored in an orderly manner and locked when not in use, and prohibited the use of expired medications. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing Services, revealed that the resident did not have a physician's order to self-administer medications and should not have had access to any medications, especially expired ones, in their room. The pharmacist confirmed that expired medications should not be used as they may become less effective. The deficiency was identified during a recertification survey, highlighting a lapse in the facility's adherence to its medication storage policy.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. On 1/22/25, the two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were removed from resident #31 room with explanation provided to resident. The expired Refresh Liquid Eye Drops were discarded. 2. Resident #31 was assessed for self-administration as per request. The resident’s wishes for self-administration were assessed by the Interdisciplinary Care Plan Team and was deemed to be capable of self-administration. The attending physician was made aware and orders received for self-administration of Refresh Eye Drops. A locked box and key were issued to resident. The plan of care was updated to include self-administration. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly, residents are promptly evaluated for potential for self-administration, a physician order [REDACTED]. B. Identification of Others: 1. All residents’ rooms were surveyed for risk of same. Individual request for self-administration and proper storage of medications were assessed by the Interdisciplinary Care Plan Team. Orders were received from the attending physician and orders updated as necessary to include self-administration. 2. All storage areas were inspected for expired medications. No expired medications were identified. C. Systematic Review to Prevent Re-Occurrence: 1. The facility Self-Administration Policy and Procedure was reviewed by the Interdisciplinary Care Plan Team. 2. The Director of Nursing developed an audit tool to audit 10 residents for expired medications, safe storage of medications, evaluation of residents to self-administer medications, and physician orders [REDACTED]. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter. 3. The DNS/Designee will be responsible for completion of audit. 4. All nursing staff were re-educated regarding expired medications, safe storage of medications, evaluation for self-administration, and physician orders [REDACTED]. D. Quality Assurance: 1. The DNS/Designee will report on the findings quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice.