Improper Storage of Insulin and Contaminated Medication Container
Penalty
Summary
The facility failed to properly store medications, specifically insulin, as per the manufacturer's guidelines. During an observation, an unopened Lantus insulin pen, an unopened insulin vial, and an insulin pen of Glargine YFGN were found stored in a medication cart instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that all insulin should be refrigerated until opened. The Director of Nursing (DON) confirmed that storing unopened insulin outside the refrigerator could decrease its potency and effectiveness, potentially leading to uncontrolled blood sugar levels in residents. The facility's policy indicated that medications requiring refrigeration should be kept in a refrigerator with a thermometer for temperature monitoring. Additionally, a multi-dose medication container of Clear Lax was found soiled and unclean in the medication cart. The LVN identified this as an infection control issue, stating that the medication bottle should always be clean to prevent contamination. The Registered Nurse (RN) and the DON both emphasized the importance of keeping medication containers clean to avoid bacterial contamination, which could make residents sick. The facility's policy stated that contaminated or soiled medication containers should be immediately removed from stock and disposed of according to procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25, Licensed Vocational Nurse (LVN) 4 removed the unopened insulin from the cart. On 3/6/25, LVN 4 re-ordered the insulin. On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the Director of Staff Development (DSD) made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications." On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the DSD made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on medications and biologicals being stored safely, securely, and properly, following manufacturer’s recommendations or those of the suppliers. This includes medications requiring "refrigeration" or "temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit" being kept in a refrigerator with a thermometer to allow temperature monitoring. The Director of Nursing (DON)/designee will conduct rounds on the facility’s medication carts daily for five days weekly for two weeks and monthly thereafter to ensure an unopened insulin is not being stored in the medication cart. On 3/12/25, the DON conducted an in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures. These should be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. The Director of Nursing/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure multi-dose medications are clean and free from particles. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of insulin and multi-dose medication being clean and free from particles for three months or until compliance is met.