Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals for five residents, leading to deficiencies in medication management. Observations revealed that a resident had bottled pills inside a plastic bag at their bedside, while another resident had a bottle labeled Zicam on their side table. Additionally, a tube labeled Zinc Oxide Ointment was found at another resident's bedside, and two bottles labeled Acetic Acid Irrigation Solution were observed on a nightstand. Furthermore, a bingo card with discontinued medication was found in the medication cart for another resident. These findings indicate a lack of adherence to the facility's policy on medication storage, which requires medications to be stored in the pharmacy or medication rooms according to specific guidelines. Interviews with staff members revealed lapses in the protocol for medication storage. One LPN admitted to conducting rounds but failed to notice medications at a resident's bedside, while another LPN stated that medications should not be at the bedside. An RN acknowledged the presence of discontinued medication in the cart, which should have been removed and returned to the pharmacy or destroyed. The facility's policy, revised in January 2018, mandates that all medications be stored according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The failure to adhere to these protocols resulted in the observed deficiencies.
Plan Of Correction
1. What corrective action will be accomplished? The bottled pills inside a plastic bag were removed from Resident #381's bedside and secured. The was removed from Resident #47's bedside and secured. The from Resident #12's bedside was removed and secured. The 2 bottles labeled Acetic Irrigation Solution were removed from Resident #47's bedside. The bingo card labeled tablet of discontinued medication for Resident #65 was returned to the pharmacy. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of occupied resident rooms and medication carts to ensure no medications or biologicals were at bedside and no discontinued medications were in the med carts. 3. Measures/systematic changes put into place: The DON/Designee re-educated the nursing staff on the facility policy for storage of medications and biologicals. Education for storage of biologicals was added to the new hire orientation and annual nursing education. The pharmacy nurse consultant will audit medication carts monthly to ensure no discontinued medications are stored in cart. The Nursing supervisor will conduct a daily audit (5 days per week) of medication carts to ensure no expired medications are in cart. 4. How corrective action will be monitored: The DON/Designee will conduct daily observation room rounds audit (times 5 weeks) to ensure no medications or biologicals are at bedside. Med cart audit for discontinued medications weekly (times 5 weeks). The results of these audits will be reviewed at the monthly QA meeting until compliance has been determined.