Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and administration of medications and biologicals. Medications with shortened expiration dates, such as inhalers and eye drops, were not consistently labeled with their opened or expiration dates, and some expired medications remained in medication carts for potential use. For example, opened Latanoprost eye drops and Trelegy Ellipta inhalers lacked proper documentation of opened and expiration dates, and expired Latanoprost eye drops were still present in the cart. Additionally, a stock supply of Silver Sulfadiazine cream was found to be opened for over a year without being discarded. There were discrepancies between medication labels and the current physician orders as documented in the medication administration records (MARs). Several medications, including gabapentin, midodrine, duloxetine, and insulin pens, had pharmacy labels that did not match the MARs, and there was no indication on the medication containers that the orders had changed. Staff, including LPNs and certified medication aides, reported that pharmacy did not replace labels when orders changed, and there was no consistent process to indicate dose changes on medication containers. This inconsistency made it difficult for staff to verify correct medication doses during administration. Temperature monitoring and documentation for medication storage areas were also found to be deficient. The refrigerator used to store medications had multiple days with missing temperature documentation throughout the year, and several days with recorded temperatures outside the acceptable range. The facility did not monitor or document the temperature of the room where medications were stored, contrary to policy requirements. The DON confirmed awareness of some issues, such as the need to date medications when opened, but was not aware of the extent of missing or out-of-range temperature documentation.