Medication Storage, Supervision, and Labeling Deficiencies
Penalty
Summary
Surveyors observed that medication carts in three stations contained unsealed red biohazard containers filled with discarded medications, including tablets, capsules, and liquids. These containers were stored with open lids in the bottom drawers of the carts, and some were labeled with handwritten notes such as 'pills,' 'liquid meds,' or 'crushed pills.' Licensed nurses reported that these bins were used to dispose of refused or dropped medications, and in some cases, controlled substances were also discarded in this manner. The Director of Nursing confirmed that these practices were not in line with facility policy, as the presence of unsealed containers with accessible medications posed risks for accidental exposure and drug misuse, and did not maintain a clean, safe, or sanitary environment for medication storage. During medication administration, a nurse prepared nine medications for a resident and placed them in two medicine cups on the resident's bedside table. The nurse then turned away to retrieve gloves, during which time the resident ingested most of the medications unsupervised. The nurse intervened before the resident took blood pressure medications, stating that blood pressure should be checked first. Interviews with supervisory staff confirmed that medications should not be left unattended with residents and that staff are required to observe residents taking their medications to ensure proper administration and to monitor for any difficulties or side effects. Additionally, surveyors found that certain medications were not labeled according to manufacturer specifications and facility policy. An opened vial of Humulin N insulin for one resident and a Breyna inhaler for another resident were both missing open dates. Staff acknowledged that labeling with open dates is necessary to determine expiration and ensure medication efficacy and safety. The Director of Nursing confirmed that the lack of labeling could result in the use of expired or ineffective medications, as staff would be unable to determine when the medications should be discarded.