Medication Storage, Labeling, and Removal Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and management of medications and biologicals. In one instance, a nurse administered insulin glargine to a resident using a pen whose pharmacy label did not match the current physician order in the electronic medical record. The nurse also failed to label the insulin pen with the date it was opened, contrary to manufacturer specifications and facility policy. The Director of Nursing confirmed that the discrepancy between the pharmacy label and the physician order posed a risk for medication errors, and that the open date was necessary to determine the insulin's expiration and potency. Another deficiency was observed when a discontinued vial of insulin lispro for a resident was found in the medication room refrigerator. The Registered Nurse Supervisor acknowledged that the medication should have been removed after discontinuation to prevent accidental administration. Review of the resident's records confirmed that the insulin had been discontinued and replaced with an oral medication, but the vial remained accessible in the refrigerator. Additional issues included the discovery of multiple eye drop medications at a resident's bedside, despite documentation that the resident was not assessed as capable of self-administering medications. The nurse present removed the medications, recognizing the risk of incorrect administration. Furthermore, expired naloxone nasal spray containers were found in a medication cart, and staff confirmed these should have been discarded as they would not be safe or effective for use. Facility policies reviewed by surveyors required proper labeling, timely removal of discontinued or expired medications, and assessment of residents' ability to self-administer medications, all of which were not followed in these instances.