Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication labeling, storage, and documentation. During a review of the medication cart, it was observed that an insulin pen for one resident was not labeled with an opened date, and two insulin vials for other residents were labeled with both opened and discard dates. Additionally, a bottle of Clonazepam, a controlled medication, was found without an accompanying controlled count sheet, despite facility policy requiring such documentation for all controlled substances, including those brought from home. The Assistant Director of Nursing confirmed that controlled medications from outside sources should be counted and documented upon arrival. The facility's policies also require that all medications be stored in locked compartments and that multi-dose containers be labeled with opened dates, which was not consistently followed. In a separate incident, a resident was found asleep in bed holding a medication cup containing several pills. The LPN stated that the medications had been given earlier and that the resident typically self-administers them, but there was no physician order or care plan documentation permitting self-administration or bedside storage of medications. The ADON confirmed that nurses are required to observe residents taking their medications and that no residents were currently approved for self-administration. These findings demonstrate failures to adhere to facility policies and accepted professional standards regarding medication labeling, storage, and administration.