Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not labeled and stored according to professional standards on two of three medication carts. Specifically, several residents' inhalers were found opened without a date of opening, and one inhaler was labeled with an expiration date that had already passed. Additionally, an insulin pen was labeled with an expiration date, but it was unclear if it was within the manufacturer's recommended usage period after opening. These findings were confirmed through interviews with nursing staff, who acknowledged the lack of proper labeling and dating on the medications. Further observations revealed that a medication cup containing pills, including a controlled substance (Oxycodone), was left unlabeled in the top drawer of a medication cart and was not double-locked as required for controlled substances. Interviews with both the day and night shift nurses confirmed that the night nurse had pre-poured the morning medications and left them unsecured for administration by the day nurse. Review of the facility's policies and manufacturers' instructions confirmed that these practices were not in compliance with established procedures for medication labeling, dating, and secure storage.