Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made by surveyors. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. The Registered Nurse (RN) supervisor confirmed the expiration dates and removed the expired kits. The Director of Nursing (DON) later stated that the expired tests could still be used due to an extended expiration date listed on the FDA website, although the specific tests found expired were not covered by this extension. Additionally, an unlocked medication cart was observed on the West side nursing station. A Registered Nurse (RN) admitted to leaving the cart unlocked because they were in a hurry to assist residents. This action was contrary to the facility's policy, which requires medication carts to be locked when not in use to prevent unauthorized access. Furthermore, a surveyor observed a Registered Nurse (RN) leaving a resident's room with a cup of crushed medication and a lancet unattended. The RN left the room to retrieve an item needed for a procedure, leaving the medication and lancet accessible. The RN later stated that they left the items because the surveyor was present, although the proper protocol is to take medications and materials with them when leaving a room. The DON and Nursing Home Administrator were informed of this incident, and it was noted that the nurse was unaware that medications should not be left unattended.
Plan Of Correction
N095-FAC Drug Storage Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on An. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass inservice and came to educate nurses on The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on -Medication Cart Audit -Treatment Cart Audit -Med room Audit. Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.