Failure to Maintain Proper Medication Storage and Labeling
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage practices, including the presence of expired and unlabeled medications in both the medication room and medication carts. Specifically, expired Diphenhydramine capsules and Beneprotein packets were found in the South Wing medication room, along with opened, unlabeled, and undated containers of Miconazole Nitrate cream and Lactulose solution. Food items such as coffee creamers, sugar packets, and a foam takeout container with utensils were also stored alongside medications. Additionally, drawers contained non-medication items like curling irons, razors, charging cords, headphones, air pumps, glasses, and hearing aids. The Director of Nursing Services (DNS) confirmed that these items should not be present in the medication room and that expired or discontinued medications should be placed in designated bins for pharmacy return, not stored in cabinets or on countertops. Further observations revealed improper storage of medications in the nursing supervisor's office, where a box of Juven packets and multiple bottles of Kayexalate were found on a shelf. The nursing supervisor was unsure why the Juven packets were there and acknowledged that the Kayexalate bottles, intended for the Pyxis system, did not fit in the drawers and should not have been stored in the office. Medication carts were also found to contain expired medications, opened and unlabeled containers, loose pills, and non-medication items such as hairbrushes, glasses, lancets, and wound care products. Staff interviewed, including LPNs and the Infection Preventionist, recognized that expired medications and non-medication items should not be stored in the carts but could not explain why these items were present. The facility's policy requires that all medications be stored in properly labeled containers, separated by route of administration, and that medication storage areas remain clean and free of clutter. The policy also mandates that opened medication containers be dated and that expired medications be removed and destroyed. Despite these policies, the facility failed to maintain proper medication storage practices, as evidenced by the presence of expired, unlabeled, and non-medication items in medication storage areas and carts. No policy on medication cart cleaning was provided upon request.