Deficiencies in Medication Storage, Labeling, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. During inspections of two medication carts, it was observed that orally administered medications were not stored separately from externally used medications, such as ointments, creams, and eye drops, contrary to facility policy. Staff, including the ADON and an RN, verified these findings. Additionally, a gentamicin ointment used for a resident's skin infection was found without an open date on its label, which was confirmed by both the LVN and the DON as a requirement for proper labeling. Further review revealed that a resident's Preparation H and Lidocaine creams were stored at the bedside without a physician's order or care plan authorizing bedside storage. The LVN responsible for administering these medications admitted to storing them at the bedside and failing to document their administration on the Treatment Administration Record (TAR) for several days. The DON and Administrator acknowledged these findings during interviews. The report also notes that the resident had the capacity to make decisions, as documented in their medical record.