Improper Medication Storage: Combining Bottles of Nuplazid
Penalty
Summary
Facility staff failed to ensure that medications were kept in their original packaging as required by policy and professional standards. Specifically, a resident with diagnoses including Parkinson's disease, repeated falls, and dementia with mild psychotic disturbance was prescribed nuplazid, which was obtained from a specialty pharmacy by the resident's daughter. The nuplazid was brought into the facility in bottles containing 30 capsules each. Instead of maintaining each bottle separately, an LPN combined pills from an opened bottle into a new bottle, resulting in the medications being stored together in a single bottle rather than in their original packaging. Interviews with the Director of Nursing, the resident's daughter, an RN, and the LPN confirmed that the practice of combining medication bottles occurred and was known to both staff and the resident's family. The facility's medication storage policy, dated October 2013, required that medications be kept in the original packaging dispensed by the pharmacy. This practice was not followed in this instance, leading to non-compliance with medication storage requirements.