Improper Medication Disposal and Unauthorized Access to Medication Storage
Penalty
Summary
The facility failed to properly dispose of expired and discontinued medications in medication storage room 1 (MSR 1), as observed when the incineration bin was found overflowing and its lid not properly closed. A Licensed Vocational Nurse (LVN) confirmed that the bin should not be overflowing, as this defeats the purpose of preventing access to disposed medications. Additionally, the facility's policy requires non-controlled substances to be disposed of in accordance with state and federal guidelines, and for medication storage areas to be maintained in a clean, safe, and sanitary manner by nursing staff. In a separate incident, a non-licensed staff member, the Central Supply Manager (CSM), was left alone inside medication storage room 2 (MSR 2) after being asked to clean up the incineration bin. The Director of Nursing (DON) acknowledged that the CSM, not being a licensed nurse, should not have been left alone in the medication room, as this allowed unauthorized access to medications. The CSM also stated she should not be handling medications without a licensed nurse present. These actions were not in accordance with the facility's policies and federal regulations regarding medication storage and access.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice. On 6/11/25, DON immediately emptied Station 1 incineration bin to biohazard container in locked area in the back next to laundry. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. On 6/12/25, DON inspected all incineration bins to ensure all bin lids were properly closed and no other deficient practice was identified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; On 06/12/25 an in-service was done to all Licensed Nurses regarding properly disposing of expired and/or discontinued medications to incineration burn bin. New form added: Task list labeled "Attention All Licensed Nurses: 8 states," 7-3 Licensed Nurses check medication room and empty incineration bin daily to biohazard bin next to laundry room. DON to check Q daily for compliance. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.