Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the labeling and storage of medications. During a medication administration, an RN was seen using an iron pill bottle that lacked a manufacturer's expiration date, with only a handwritten date indicating when the bottle was opened. The RN was unaware of the significance of the handwritten date and could not determine the expiration date of the iron pills, yet proceeded to administer the medication and returned the bottle to the medication cart for future use. Additionally, an LPN was observed improperly disposing of two pills by placing them in a medication cup with pudding, then removing and discarding them in an open, unlidded garbage can attached to the medication cart. The pills remained visible and accessible, and the medication cart was left unattended in a room with ambulatory residents. The LPN was unfamiliar with the facility's policy for disposing of non-controlled substances. Further deficiencies were identified in medication administration practices. One resident was found to have a medication cup with four pills left on their overbed table, while the resident was not present in the room. The LPN responsible for administering the medications admitted to leaving the medications at the bedside and not observing the resident consume them, contrary to facility policy. The DON confirmed that nurses are required to observe residents taking their medications before documenting administration. Another incident involved a resident who possessed marijuana gummies in their room and had shared at least one gummy with another resident. The resident admitted to having the gummies and eventually surrendered an opened bag to staff, who placed it in the narcotic box of the medication cart. The DON and ADON were unaware of the incident and could not provide information on the facility's policy regarding cannabis products. The facility's policy on cannabidiol (CBD) indicated that such products should be administered by licensed nurses with a physician's order and treated as controlled substances, with strict documentation and counting procedures.
Plan Of Correction
F761 – Label/Store Drugs & Biologicals Element #1: Resident #35 and #36 were assessed by the Director of Nursing or Designee to ensure no lasting effects related to the improper storage of medications. Element #2: A full-house medication storage audit was conducted across units to identify and correct any additional labeling or storage violations. Element #3: The Administrator reviewed the policy on Medication Storage, and Destruction of Unused Drugs and updated as necessary. Licensed Nurses will be re-educated on the policy and procedures for Medication Storage and the Destruction of Unused Drugs. Element #4: The Director of Nursing and/or designee will conduct weekly inspections of the medication storage areas and medication carts to ensure compliance with storage and destruction. The Social Service Director and/or designee will conduct a weekly sweep of 10 resident rooms to ensure residents without approved assessments and equipment are not self-administering. Compliance Date: 6/20/2025