Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to properly store medications in three of four medication carts, specifically the West cart, Founder Cart, and Lake Cart. During an observation, it was noted that the West medication cart contained an opened multi-dose foil package of Ipratropium/albuterol without a date. This was confirmed by RN Employee E2, who acknowledged that the medication should have been dated when opened. Similarly, the Founder's medication cart also had an opened multi-dose foil package of Ipratropium/albuterol without a date, confirmed by LPN Employee E3. Additionally, the Lake medication cart was found to have an opened Xdemvy eye drop container without a date, which was confirmed by RN Employee E4. The Director of Nursing later confirmed that the facility failed to properly store medications in these three medication carts. The facility's policy on the disposition of medications, which requires that expired or no longer required medications be properly dispositioned, was not adhered to, leading to this deficiency.
Plan Of Correction
1. Undated multidose foil package breathing treatments and the eye drops were disposed of on 03/03/2025 and 03/04/2025. 2. Following the findings, the medication carts were audited for other undated multidose foil package breathing treatments or eye drops. None were found. 3. DON/designee educated RNs and LPNs on the need to date multidose foil package breathing treatments and eye drop containers when they are opened. 4. DON/designee will audit med cart three times a week for 2 weeks and weekly thereafter until substantial compliance is achieved. 5. Results of the audits will be reported at the quarterly QA meeting.