Failure to Label and Secure Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and secure storage of medications, specifically insulin pens and Tuberculin PPD solution vials, for several residents. During inspection of medication carts, two open insulin pens were found without open or expiration dates, and one insulin pen was found to be expired. These pens belonged to two residents and were not immediately removed from the cart as required. Additionally, a nurse was seen leaving insulin pens unsecured on top of a medication cart while attending to other tasks. Medication Administration Records confirmed that the insulin pens were actively being used for residents with orders for insulin administration. Further inspection of the medication room refrigerator revealed two open Tuberculin PPD vials that were not labeled with open dates. Staff acknowledged that these vials should be dated and that they are used for new admissions requiring TB skin tests. Records showed that three recently admitted residents received doses from these vials. Facility policies require all opened medication vials to be labeled with the date opened and expiration date, and all medications to be stored securely, but these procedures were not followed as observed during the survey.