Deficient Medication Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices across several medication rooms and carts. Unlabeled and discontinued medications, including Linzess and Gavilyte-G, were found stored in active medication storage areas in two medication rooms. Some medication bottles lacked full pharmacy labels, displaying only small labels on the caps, and staff were unable to explain the absence of proper labeling. Discontinued or one-time use medications were not removed from active storage, contrary to facility expectations, and staff interviews confirmed uncertainty about proper storage procedures. In one medication cart, a hazardous liquid medication, Valproic Acid, was found with visible spills on the outer surface of the bottle. Staff acknowledged that while gloves are typically used to administer this medication, there was a risk of inadvertent skin contact when searching for other medications in the cart. Additionally, another medication cart contained pre-pour medication bins with sticky, brownish spills and broken sections, and staff were unsure of the origin of the residue or the last time the bins were cleaned or replaced. Further deficiencies were observed in the storage of supplies and discontinued medications under sinks in two medication rooms, where staff could not provide a rationale for this practice. Medication refrigerators were also found to be outside the recommended temperature range, with one refrigerator above and another below the accepted range. Staff interviews confirmed awareness that improper storage temperatures could affect medication efficacy, and facility policies required medications to be stored at appropriate temperatures and for discontinued or expired medications to be separated and destroyed or returned according to guidelines.