Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, leading to deficiencies in medication management. During the recertification survey, it was observed that two of the five medication carts and one of the three medication storage rooms contained medications without proper labeling of opened or discard dates. Specifically, the 3 North A side cart had multiple medications, including eye drops, insulin vials, and inhalers, without opened or expiration dates. Similarly, the 2 North A side cart had diabetic pens without opened or discard dates, and the 3 North medication refrigerator contained expired vials and others without opened dates. Additionally, the 3 South B side medication cart was found unlocked and unattended in a common resident hallway, posing a risk of unauthorized access. Interviews with nursing staff revealed that the responsibility for labeling medications with opened dates was not consistently followed, and there was a lack of adherence to the facility's policy on medication storage. Nurses acknowledged that without opened dates, the effectiveness of medications could not be guaranteed, and expired medications might be administered inadvertently. The Director of Nursing confirmed that medications should be dated when opened to ensure their effectiveness and that medication carts should be locked when unattended. The facility's policy required that outdated medications be removed from inventory and that medication carts be audited weekly to ensure compliance. However, these procedures were not effectively implemented, leading to the observed deficiencies in medication management.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Dispose of opened and unlabeled medications from Med carts 3 North A and 2 South A, and influenza vaccine vials and tuberculin vial from 3 North Medication Storage Room. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit all medication carts, rooms, and refrigerators. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Educate all nurses on medication labeling and storage. - Educate all nurses on locking medication carts when left unattended. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all medication carts, rooms, and refrigerators x1 per unit/week for 3 months until 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager.