Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on two of the three medication carts reviewed during the survey. Specifically, an opened insulin pen and an ophthalmic solution bottle were found without documented open dates on the Unit 4 West medication cart. The facility's policy requires that multi-dose vials be dated upon opening and discarded within 28 days unless otherwise specified by the manufacturer. Resident #92, who had intact cognition, was receiving insulin injections, and Resident #98, who had severe cognitive impairment and impaired vision, was using the ophthalmic solution. The lack of open dates on these medications meant that staff could not determine when they should be discarded, potentially affecting their efficacy and safety. Additionally, on the Unit 2 East medication cart, an opened Humalog insulin pen for Resident #436 was also found without an open date. This resident had intact cognition and was taking hypoglycemic medication. Interviews with nursing staff and the pharmacist confirmed that insulin pens should be discarded 28 days after opening, and all open medications should have the open date documented. The Director of Nursing Services reiterated that nurses are responsible for ensuring proper labeling and storage of medications, and discontinued medications should be removed from the medication cart.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #92: The opened [MEDICATION NAME] pen was immediately removed and replaced with a properly labeled pen reflecting the current date of opening. Medication administration was not interrupted, and the resident was not harmed. - Resident #98: The discontinued [MEDICATION NAME] Ophthalmic Solution was immediately discarded upon identification. Resident’s active medications were reviewed to ensure no expired or discontinued medications remained on hand. - Resident #436: The improperly labeled Humalog insulin pen was discarded, and a new insulin pen with a documented open date was initiated per physician order. Resident continued to receive timely insulin administration without clinical consequence. II. Identification of other residents - A facility-wide audit of all medication carts and medication storage areas was conducted on 3/21/2025 by the Director of Nursing (DON) and Unit Nurse Managers. - The audit focused on: All multi-dose vials, insulin pens, and ophthalmic solutions in use. Verification that each item was appropriately labeled with the date opened. Removal if any expired or discontinued medications are observed. - There were no negative findings from this review. III. Systemic Changes - The facility policy titled Storage of Medications was reviewed and found to be in compliance with the regulations. - All licensed nurses will be re-educated on the proper handling of open and/or expired medications including: All medications that require discarding within a specific time frame or shortened expiration dates once opened (e.g., 28 days after opening) must be labeled with the date opened upon first use. All discontinued medications must be removed from the cart or storage area immediately. A medication must not be used unless it is properly labeled. - A copy of the attendance sheet will be kept on file for validation. - The Pharmacy Consultant will reinforce labeling and storage requirements in monthly audits and report deficiencies in real time to the DON. IV. QA Monitoring - The RN Supervisor will conduct weekly medication cart and medication refrigerator audits for 4 weeks, verifying: - All opened medications have a clear, legible open date. - No expired or discontinued medications are present. - After 4 weeks of 100% compliance, audits will continue monthly for 3 months, then be reviewed for integration into routine quarterly pharmacy audits. - Results will be reported to the QAPI Committee monthly. Any trends in noncompliance will prompt immediate re-education and performance improvement plans. Responsible Party: Director of Nursing