Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. During inspections of medication carts and storage rooms, numerous instances were found where drugs and biologicals were not properly labeled, such as opened multi-dose insulin pens without open dates and vials of Lorazepam stored in unlabeled or improperly labeled bags. Expired medications, including Lorazepam, were found in unlocked refrigerators, and staff confirmed these should have been destroyed but were not. Additionally, some medications lacked pharmacy labels or had handwritten names, and there were medications present for individuals not currently residing in the unit. Medication carts were found to be physically compromised, with missing drawers creating large openings that exposed narcotic lock boxes. These carts were observed unattended in hallways, with the narcotic drawers accessible to residents, including those who were mobile and cognitively impaired. Staff interviews confirmed that the carts had been in this condition for extended periods, and that narcotics could be accessed through the openings. The facility's Director of Nursing and other staff acknowledged awareness of these issues, including the lack of double-lock security for controlled substances and the absence of narcotic count sheets for expired medications. Further deficiencies were identified in the management of emergency kits (E-kits). Kits were found unsealed, unlocked, and missing required inventory documentation. Staff were unclear on the procedures for retagging and inventorying the kits after use, and there was confusion regarding the presence and use of medications within the kits. The lack of proper labeling, security, and documentation for both routine and emergency medications was confirmed through staff interviews and direct observation, in violation of the facility's own medication storage policy.