Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made during a survey. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. Staff S, a Registered Nurse supervisor, confirmed the expiration dates and removed the expired kits. Despite the Director of Nursing (DON) stating that the expired tests could still be used due to an extended expiration date listed on the FDA website, the presence of expired items in the storage room indicates a lapse in the facility's protocol for monitoring and removing expired supplies. Additionally, an unlocked medication cart was observed on the West side nursing station. Staff U, an RN, acknowledged that the cart should have been locked when unattended but admitted to forgetting due to being in a hurry to assist residents. This oversight highlights a failure to adhere to the facility's policy that requires medication carts to be locked when not in use, ensuring that medications are not accessible to unauthorized individuals. Furthermore, in the room of a resident, Staff H, an RN, left a cup of crushed medication mixed in water and a lancet unattended while retrieving an item to assist with a procedure. Staff H later explained that the presence of the surveyor led to the oversight, but acknowledged that the proper protocol is to take medications and materials when leaving a resident's room. This incident underscores a breach in the facility's policy for safe and secure medication storage and handling, as medications should not be left unattended to prevent potential misuse or errors.
Plan Of Correction
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. An 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. 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.