Failure to Properly Label and Store Medications in Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals in three medication carts were not labeled or stored according to facility policy and professional standards. Specifically, undated used bottles of Latanoprost eye drops, Breo inhalers, and a Combivent inhaler were found in one cart, with packaging indicating expiration periods after opening but lacking any opening dates. Another cart contained an opened bottle of Ibuprofen without an opening date, which was only labeled after the surveyor's observation. A third cart had an undated empty bottle of Omeprazole, undated used bottles of Latanoprost, Loteprednol, and Timolol eye drops, and an undated used Breo inhaler, again with no indication of when these medications were opened. Interviews with LPNs revealed a lack of consistent practice in labeling medications upon opening, and one LPN was unfamiliar with the facility's pharmacy procedures due to being new. The DON confirmed that all medications should be labeled with the date opened and expiration date, and acknowledged the presence of agency staff as a contributing factor. A review of facility policies showed clear requirements for labeling medications with opening and expiration dates, and for removing outdated or improperly labeled medications from inventory. The policies also specified that certain medications require a shorter expiration period once opened, and that any medication found without a date should default to the date dispensed. Despite these policies, the observed medication carts contained multiple items that were not labeled as required, indicating a failure to follow established procedures for medication labeling and storage.