Improper Storage and Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. This deficiency was identified during a recertification survey for a resident with Dry Eye Syndrome and Cataract, who was observed to have a plastic cup containing two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment on their bedside table. The resident self-administered the expired Refresh Liquigel eye drops, which were not stored in a locked compartment, and there was no documentation of an assessment or comprehensive care plan allowing the resident to self-administer medications. Interviews with facility staff, including LPNs and the Director of Nursing Services, revealed that the resident did not have a physician's order to self-administer medications, and the presence of expired medications in the resident's room was against facility policy. The pharmacist confirmed that expired medications should not be used as they may become less effective. The Director of Nursing Services acknowledged that the resident should not have had access to any medications without proper evaluation and orders.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. Resident #31 who still resides in the facility was affected by this deficient practice. 2. On 1/22/25, two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were in the resident’s room and were not secured. The medications were removed from resident #31 room immediately with explanation provided to resident. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly. B. Identification of Others: 1. All residents’ rooms were surveyed for risk of same. No resident was identified at risk of this deficient practice. 2. The Policy and Procedure titled Storage of Medications was reviewed by the Interdisciplinary Care Planning Team and no changes were made. C. Systematic Review to Prevent Re-Occurrence: 1. The Director of Nursing developed an audit tool to audit 10 residents to ensure safe storage of medications for residents who are care planned for self-administration and all areas where medications are stored. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter or until 100% compliance. 2. The DNS/Designee will be responsible for completion of audit. 3. All nursing staff were re-educated regarding safe storage of medications. E. 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.