Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that one of four medication carts (Unit A medication cart 1) was left unlocked and unattended, contrary to the facility's policies and procedures regarding medication security. The administrator confirmed the cart was unlocked with no staff present, and a Licensed Vocational Nurse (LVN) admitted to forgetting to lock the cart when leaving to attend to a resident. Interviews with other nursing staff confirmed that medication carts are required to be locked at all times when unattended to prevent unauthorized access. Further observations and interviews revealed that medications and biologicals were not properly stored or labeled for several current and discharged residents. For one discharged resident, an antibiotic bubble pack with remaining doses was found in a medication cart, and staff could not account for all doses or provide documentation of their destruction. The facility's policy requires unused medications to be removed from storage and destroyed in the presence of two licensed healthcare professionals, with proper documentation, but this process was not followed. Additional deficiencies included improper storage of an unopened Lantus SoloStar insulin pen, which was found at room temperature in a medication cart instead of being refrigerated as required by manufacturer instructions. Multiple discontinued, controlled, and bedhold medications for residents who were either transferred or discharged were also found stored in medication carts alongside active medications. Staff interviews confirmed that these medications should have been removed from the carts and stored separately or destroyed according to facility policy.