Medication Labeling, Storage, and Security Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and disposal of medications on two of three medication carts. Specifically, opened insulin vials were found to be kept beyond their 28-day expiration period, and staff acknowledged these should have been discarded. Additionally, a medication cart contained a cup with six unidentified medications labeled only with a resident's handwritten name, as well as an unlabeled bottle of nitroglycerin and an EpiPen in a plastic bag with only a handwritten name, lacking required pharmacy labeling. Staff confirmed these medications were not properly labeled and should have been returned to the emergency cart if not needed. Further deficiencies were identified in medication security and storage. One resident was found to have multiple tablets of Imodium AD and generic loperamide unsecured at their bedside, with no physician orders for their use or for keeping medications at bedside. The resident reported that the medications were brought in by a family member, and staff confirmed that such medications should not be kept in resident rooms. In the medication storage room, two emergency medication kits containing controlled substances (Ativan) were found unsealed, and staff stated that these were not being counted to monitor for diversion. Additionally, controlled medications awaiting destruction were stored in a locked safe, but staff reported that no counts were performed on these medications during the waiting period.