Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed that medications were not stored and labeled according to professional standards and facility policy on two medication carts. On one cart, three medication cups containing medications were found in a drawer, each labeled with numbers, after a nurse prepared them for residents who were not present at the time of administration. The nurse acknowledged that facility policy requires discarding medications if not administered and prohibits pre-pulling medications. Additionally, four bottles of eye drops and a bag of nebulizer medication were found without opened dates, despite the requirement to date medications upon opening due to shortened expiration periods. On another medication cart, two bottles of eye drops were also missing opened dates, and a narcotic card for Tramadol showed a discrepancy between the physical count and the narcotic sign-out sheet, with one tablet unaccounted for and no corresponding documentation in the medication administration record. The nurse responsible admitted to administering the medication but forgetting to sign it out. Facility policies reviewed confirmed the need for dating opened medications and maintaining accurate controlled substance records, including immediate documentation of administration.