Deficient Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals across all resident floors. Unattended and unlocked medication and treatment carts were observed on several occasions on the 3rd, 4th, 5th, 6th, and 7th floors, with prescription creams, ointments, insulin syringes, wound care supplies, and even scalpels left accessible. In many instances, no staff were present in the vicinity of these carts, and residents were observed nearby or moving through the area. Staff interviews confirmed that carts were sometimes left unlocked, including during night shifts when residents were presumed to be sleeping, and staff acknowledged that this practice was not in accordance with facility policy. Medication refrigerators on the 3rd, 4th, and 7th floors were found without daily temperature monitoring as required by facility policy. Temperature logs were missing entries for several days, and in one case, the refrigerator temperature was found to be outside the recommended range. Staff interviews revealed a lack of knowledge regarding the appropriate temperature range and the importance of daily monitoring to ensure medication efficacy. Additionally, several insulin pens and other medications were found without open dates on the 3rd, 5th, and 6th floors, making it impossible to determine if the medications were still within their effective use period. Staff stated that without open dates, they could not verify the safety or effectiveness of the medications. The facility also failed to manage discontinued medications appropriately. Excessive quantities of discontinued or expired medications were found stored in medication rooms on the 4th and 7th floors, with staff unable to describe a consistent process for their timely removal or return to the pharmacy. Interviews with nursing staff and the Director of Nursing indicated uncertainty about the frequency of pharmacy pickups and the process for handling discontinued medications. The accumulation of these medications in unsecured areas was acknowledged as inappropriate by the Director of Nursing, who noted the risk of medication diversion.