Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on the fourth-floor medication cart and in the second-floor medication room. During an observation on the fourth-floor medication cart, it was found that a Novolog Insulin pen, a Lantus Insulin pen, and a Basaglar Insulin pen were opened and undated. Employee E10, a licensed nurse, confirmed that these insulin pens should have been dated when opened. Similarly, an observation in the second-floor medication room refrigerator revealed an opened and undated PPD vial and an Acetylcysteine vial. Employee E11 confirmed that these medications should have been dated upon opening. The manufacturer's guidelines for these medications specify that they must be discarded after a certain period once opened. Novolog, Lantus, and Basaglar Insulin pens should be discarded 28 days after opening, while the PPD vial should be discarded after 30 days due to possible oxidation and degradation. The Acetylcysteine vial should be used immediately after opening and discarded after four days. The failure to date these medications upon opening indicates non-compliance with the manufacturer's guidelines and the facility's responsibility to ensure proper medication management.
Plan Of Correction
1. The novolog Insulin that was opened and not dated was discarded. The lantus insulin that was opened and not dated was discarded. The basaglar insulin kwikpen that was not dated when opened was discarded. The Apisol that was not dated when opened was discarded. The Acetylcysteine that was not dated when opened was discarded. 2. Facility completed a house audit and no other multi-dose vials were discovered not dated when opened. 3. DON, or designee, will educate licensed staff on dating multi-dose vials when they open them. 4. DON, or designee, will perform random audits to ensure multi-dose vials are dated when opened weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.