Failure to Properly Label, Secure, and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled, secured, and stored according to accepted professional standards. Surveyors observed three unattended and unlocked medication carts on one wing, and an unlabeled bottle of Azelastine HCl 0.05% eye drops prescribed for a resident, which lacked an open date. Additionally, a plastic container with oxycodone 20mg tablets, labeled with the names of recently admitted residents, was found in an old zip lock bag. An expired Nisus NPWT Canister was also found in the medication storage room. Staff interviews confirmed that multi-use eye drops should be discarded 28 days after opening, and the findings of unlabeled, expired, and improperly stored medications were acknowledged by nursing staff and the DON. On another wing, a round white pill was found on the resident hallway floor, and an LPN disposed of it in the medication cart trash can. Surveyors also observed an unattended and unlocked medication cart on this wing, which was acknowledged by the Regional DON and the nurse assigned to the cart. The nurse confirmed that the facility's expectation is for medication carts to be locked when not in use.