Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice, as observed during a recertification survey. Specifically, the West Unit Team 1 medication cart contained opened medications, including vials of insulin and other medications, without open or expiration dates. Additionally, several bottles of eye drops lacked labels identifying the resident and did not have open or expiration dates. This deficiency was identified through observation, record review, and interviews with facility staff. Interviews with staff revealed a lack of adherence to the facility's policy regarding medication labeling. A Licensed Practical Nurse (LPN) stated that medications were labeled by the pharmacy, but acknowledged that labels on eye drops had fallen off, and they did not write expiration dates on the bottles. The Assistant Director of Nursing confirmed that it was the nurse's responsibility to label medications with open and expiration dates upon opening. The Director of Nursing reiterated that nurses were trained to label medications and check expiration dates before administration. Despite this training, the deficiency was noted, indicating a lapse in following established procedures.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: Immediate inspection of the West Unit Team 1 medication cart was performed and any medications found without label or date were appropriately disposed of and new ones were supplied by pharmacy and appropriately stored, labeled and dated per policy. Identification of other residents and corrective action: All residents are at risk for this deficient practice. All medication cart drawers were checked and any medications found without label or dated will be appropriately discarded and new ones will be supplied by pharmacy that are appropriately stored, labeled and dated per policy. Measures and Systemic Changes: Medication Administration Policy reviewed no changes. All nurses will be educated on policy regarding proper labeling and storage of medication. Monitoring: Auditing will be done twice a week for one month, then weekly for one month, then biweekly for one month. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: 3/31/25 Lynne Kaiser ADON