Improper Medication Storage and Labeling in Medication Room
Penalty
Summary
Surveyors observed that the Love Unit Medication Room contained a refrigerator with an opened multidose tuberculin vial that was not dated at the time it was opened. When questioned, an LPN was unable to provide information on when the vial was opened and acknowledged that it should have been dated upon opening. This failure to date the medication vial is not in accordance with the facility's policy and accepted professional standards for medication labeling and storage. Additionally, the same refrigerator contained a urine sample belonging to a newly admitted resident. The LPN confirmed that the refrigerator is designated solely for medication storage and that storing a urine sample in this location was inappropriate. The facility's pharmacy policy specifies that potentially harmful substances and non-medication items must be stored separately from medications, and that outdated or improperly labeled medications should be immediately removed from inventory.
Plan Of Correction
F761 1. The Love unit med room refrigerator was immediately audited, all non-medications were removed, and medications/vaccines that were not dated were removed and discarded. 2. A sweep of all med room refrigerators was performed by 4/25/2025 to ensure they are used only for medications and/or vaccines, and all vaccines are labeled appropriately. 3. The policy on Medication labeling and storage was reviewed and deemed appropriate. Licensed nurses were educated on proper procedure by 4/25/2025 by the DON/designee. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure medications are stored appropriately and expired medications are discarded. 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.