Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors observed that in the Faith Unit medication room, a multidose vial of opened tuberculin solution did not have an opened date on the vial, box, or packaging. The Registered Nurse (RN) Unit Manager confirmed that staff were required to date multidose vials when opened to ensure timely disposal. In a subsequent observation in the same medication room, another opened tuberculin vial was found without an opened date on the vial, though the box was dated. The RN Unit Manager stated that both the vial and the box should be dated in case they become separated. Manufacturer instructions indicated that vials in use for 30 days should be discarded, highlighting the importance of proper dating. Additionally, in the Love Unit, an unlocked and unattended medication cart was observed. The cart was left unattended while the LPN responsible for it was distracted at the nurse's station and did not lock the cart before leaving. Facility policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with specific requirements for expiration dating and storage. These observations demonstrate failures in medication labeling and secure storage practices as required by federal regulations and facility policy.
Plan Of Correction
F761 1. No specific residents were identified in this citation, both undated TB vaccine vials were discarded immediately upon discovery and the nurse who left the med cart unlocked and unattended was provided on the spot education. 2. The facility provided a sweep of the medication rooms and medication carts by 6/6/2025 to identify improperly dated medications, any found were immediately discarded. 3. The policy on labeling, dating and storage of medications was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on proper procedure, including the importance of securing unattended medication carts by 6/6/2025. Labels were requested from pharmacy for the purpose of ensuring vials are dated appropriately. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of medication rooms and carts to ensure appropriate labeling is done and unattended carts are properly secured. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.