Failure to Properly Label, Date, and Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards and facility policy. Multiple medication carts and medication refrigerators contained insulin pens and vials that were either expired, not labeled with the resident's name, or not dated when opened. Specific examples included expired Basaglar and Humalog insulin, Lantus Solostar insulin without a resident's name, and several instances of Lispro, Glargine, Novolin N, and Levemir insulin that were not dated when opened or not labeled with the resident's name. Additionally, a bottle of Tylenol was found with an expired date. Interviews with nursing staff revealed a lack of consistent knowledge and adherence to the facility's policies regarding medication labeling and expiration dating. Some LPNs were unaware of the required timeframes for insulin use after opening, and others acknowledged that medications should be dated and labeled but failed to ensure this was done. The facility's own policies required dating vials or devices after first use and specified shortened end-of-use dating for certain products, but these procedures were not consistently followed. The surveyors also found that the process for checking medication carts and refrigerators for expired or improperly labeled medications was not reliably implemented. Nurses reported that checks were supposed to occur monthly with random audits, but expired and unlabeled medications were still present. The lack of proper labeling and dating was observed across multiple units and involved several residents' medications, indicating a systemic issue with medication management practices within the facility.