Improper Medication Handling and Storage
Penalty
Summary
Nursing staff at the facility were observed and reported to have improperly handled and stored medications by pre-pouring pills for multiple residents into medication cups, labeling them with resident names, and leaving them unattended on top of medication carts. This practice was witnessed by both family members and staff, with specific instances noted where LPNs prepared medications for several residents at once and left the cups exposed and accessible, rather than administering medications to one resident at a time as required. Interviews with staff confirmed that it was a common practice to prepare medications in advance for multiple residents, especially when several residents were seated together. Staff would place the medications in labeled cups and deliver them to the group simultaneously, rather than following the protocol of preparing and administering medications individually. The DON acknowledged that this was not in accordance with facility policy, which requires medications to be prepared and administered to one resident at a time, with documentation completed immediately after administration. Facility policy and national guidelines were reviewed, both of which emphasize the importance of proper medication labeling, storage, and administration to prevent errors. The facility's own policy requires that medications be documented at the time of administration and not prepared in advance. The observed and reported practices directly contravened these requirements, resulting in a deficiency related to the safe handling and storage of drugs and biologicals.