Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals on one of three nursing units, one of two medication rooms, and two of three medication carts. On the Second Floor nursing unit, a cardboard box containing various medications and biologicals was found under a desk at the nurse's station. These included TPN bags, Lovenox syringes, Tuberculin solution vials, and other medications, some of which were opened. A Registered Nurse acknowledged that the box contained medications intended for disposal, but the facility had not yet determined which were returnable or needed destruction. In the Third Floor Medication Room, several medications were improperly stored. Resident R31's Lopressor suspension had a "do not use after" date that had passed, and other medications like Gabapentin and lispro insulin vials were open without noted open dates. Additionally, expired needles were found among the supplies. A Licensed Practical Nurse confirmed these observations, indicating a failure to adhere to proper storage protocols. Further issues were identified during reviews of medication carts on the Third Floor. Expired insulin pens and pens lacking resident identification were found on both the South and East medication carts. Interviews with LPNs and the Director of Nursing confirmed these deficiencies, highlighting the facility's failure to maintain proper storage and labeling of medications across multiple areas.
Plan Of Correction
The observed 2nd floor box of medication was returned to pharmacy. The observed medication in the third-floor medication room were returned to pharmacy. Medication rooms and medication carts were audited; any expired meds or supplies were destroyed. The DON/designee completed an audit of all medication carts and medication rooms to ensure medications are stored and labelled appropriately. There were no negative findings. To prevent this from recurring, the RDCS/designee educated licensed nursing staff on requirements of F761 and proper storage, labelling, and returning/destruction of medications. To monitor and maintain ongoing compliance, the DON/designee will audit medication carts and medication room/refrigerators weekly x4, then monthly x2 to ensure medications are stored, labelled, and returned/destroyed appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.