Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in one of two medication rooms and two of four medication carts. Specifically, in the second-floor medication room, a drug disposal container and a clear plastic bag were found under the sink, and the refrigerator contained opened and undated sterile water and cathflo, along with an envelope containing cash money. Additionally, a gray plastic bag with shoes was found on the floor. On the second-floor west medication cart, several opened medications, including fluphenazine decanoate, Lantus insulin, and amantadine, were not labeled with dates. Similar issues were observed on the first-floor west medication cart, where multiple opened medications, such as Miralax, timolol eye drops, and lactulose solution, were not labeled with dates, and a can of Red Bull was found, which was suspected to belong to a staff member. Furthermore, the facility failed to secure treatment medications at a resident's bedside. Resident R69, who was admitted with diagnoses of high blood pressure, anxiety, and depression, had several medical items, including iodine solution, medical tape, Silvadene cream, saline solution, and scissors, unsecured on their bedside stand. These observations were confirmed by Registered Nurse Employee E16, who removed the items from the room. The facility's policies on medication storage and resident self-administration of medications were not adhered to, leading to these deficiencies.
Plan Of Correction
1. DON/designee to complete whole house audit for medications at bedside, med rooms, med fridges and under sink storage areas. 2. Residents experienced no adverse effects. Resident R69 was not self-administering any medications or treatments during observation. 3. All medications not properly stored in medication carts/rooms were disposed of per policy protocol immediately. 4. DON/designee to educate licensed staff on medication administration and medication storage, including labeling and dating of meds/treatments upon opening for accurate use by date. 5. DON/designee to audit medication carts and rooms for appropriate med storage, meds at bedside and proper med labeling/dating upon opening 3x/week for 2 weeks, then 1x/week for 4 weeks. 6. Results to be submitted to QAPI for review and approval.