Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and administration policies in two distinct instances. In the first instance, an unsecured and unlabeled round white pill was found on a resident's dresser during an observation. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 11 and diagnoses including COPD, CHF, dementia, and CVA, was unaware of the pill's presence. Multiple staff interviews confirmed that medications should not be left unsecured or unattended in resident rooms, and that the nurse should observe the resident taking the medication or properly dispose of it if dropped. The facility's own policies and professional references reviewed also emphasized that medications must be secured and not left at the bedside or in resident areas. In the second instance, two bottles of Erythromycin Ophthalmic Ointment were found in a medication cart with incorrect expiration dates. The bottles were labeled to expire 30 days after opening, but the manufacturer's guidelines specified a 28-day expiration period. Staff interviews, including those with the RN, DON, and pharmacy consultant, confirmed that medications should be labeled with the correct expiration date and that expired medications could lose efficacy. The facility's policies and job descriptions for nursing staff and the DON outlined responsibilities for ensuring proper medication storage and administration, including checking for expired medications. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and professional guidelines. The findings demonstrated lapses in following established procedures for medication security and accurate labeling, as required by both facility policy and accepted professional standards.