Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. In the 200 Hall medication storage room, expired Assure Prism glucose control solutions were found, with no open dates on the bottles or boxes, and no unexpired control solutions available. Additionally, medications in bubble packaging were found in a medication cart without any identifying information such as resident name or room number. The nurse present was unable to identify the owner of these medications and indicated that they would use the medication since it had already been signed out for a resident. In the 300 Hall medication room, opened betadine solution and wound dressings were found without open dates, and a white powder residue was observed on one bottle. Glucose test strips were also found opened and undated, contrary to facility policy as described by the nurse. Further observations revealed that keys to the treatment cart, which contained prescription medications and treatment supplies, were left on top of the cart and accessible to multiple staff members. The nurse explained that due to having only one set of keys, they were left with the cart for shared access. The treatment cart contained various prescription medications and wound care supplies. Additionally, a nurse aide was observed being given keys to the medication room to retrieve an ice pack, entering the room unattended. The medication refrigerator inside the room, which contained insulin pens and vaccinations, was found unlocked, and nurse aides were allowed to access the room without supervision, contrary to the statements of the nurse supervisor. Interviews with nursing staff and the Director of Nursing confirmed that medication storage and access practices did not align with facility policy or professional standards. Staff acknowledged that items such as glucose control solutions, test strips, and wound care supplies should be dated when opened, and that medication carts and rooms should remain secure. The lack of proper labeling, storage, and security for medications and biologicals was consistently observed across multiple medication rooms and carts.