Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications throughout the facility. Observations revealed that medication carts contained expired, undated, and loose medications, including vials of Albuterol/Ipratropium nebulizer medication not stored in their original packaging, an unlabeled vial without a resident name, and open bottles of Latanoprost ophthalmic drops and liquid protein that were not dated. Additional findings included loose pills and expired medications in medication carts, as well as expired Bisacodyl suppositories and vancomycin IV bags in the medication storage room. Staff interviews confirmed that nurses are responsible for cleaning their own carts, but expired and loose medications were still present. Controlled substances were not properly secured, as locked narcotic boxes in medication refrigerators were attached to removable shelves, making them unremovable as required. An emergency drug kit containing Lorazepam, a controlled substance, was also not securely attached in the refrigerator. CPR carts on two halls were found unlocked and contained glucose gel, and staff confirmed that all nurses have keys to these carts. Additionally, medications were observed left unsecured on top of medication carts and in resident rooms, including antacid tablets and an antibiotic vial at bedside, despite no residents being approved for self-administration of medications. Facility policy requires all drugs and biologicals to be stored in locked compartments and under proper conditions, with controlled substances in separately locked, permanently affixed compartments. The policy also mandates that medications must be under direct observation or locked during medication passes, and that expired or unused medications are to be routinely removed. Despite these policies, surveyors found multiple instances where medications were not properly labeled, stored, or secured, and staff interviews confirmed lapses in adherence to these protocols.