Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an unlocked and unsecured medication cart on the first floor, which was accessible to residents, family, and staff. This was observed while a registered nurse was attending to a resident in a room. Additionally, loose pills were found in the second drawer of the medication cart, not in their original pharmacy packaging, which was confirmed by an LPN to be inappropriate. Furthermore, the facility did not store unopened and unused multi-dose containers of insulin according to the manufacturer's instructions. An unopened Insulin Aspart Pen Injector for a resident was found in the medication cart instead of being refrigerated as required. The facility also failed to store refrigerated controlled medications in a separately locked, permanently affixed container. A red plastic box containing Ativan Intensol was not permanently affixed to the refrigerator, allowing it to be removed, which was confirmed by the Assistant Director of Nursing.
Plan Of Correction
All medication carts were rounded on and ensured to be locked. Any loose medication within the drawer of the medication cart was destroyed by nursing staff via drug buster. The insulin pen within the medication cart was immediately discarded. Controlled substance contents was moved to a permanently affixed box within the refrigerator that was preexisting. A Facility-wide sweep was conducted to include: all medication carts to ensure that they are locked when not in use; that there are no loose medications in the drawers; and that all insulin is dated once removed from the refrigerator. In addition, a facility-wide sweep of medication room refrigerators was conducted to ensure that all controlled substance boxes are permanently affixed to the refrigerator. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on the policies including but not limited to medication storage, disposition and labeling. The director of nursing (DON) or designee will conduct audits to ensure that all med carts are locked when not in use, no loose medications are left in the med cart, all insulin pens are dated when outside of the refrigerator and all controlled substance boxes in the medication room refrigerators are permanently affixed, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.