Medications Removed from Original Packaging Prior to Administration
Penalty
Summary
Nursing staff failed to ensure that medications and biologicals were stored in their original packaging until the time of administration for 18 residents reviewed for medication storage. During observations, surveyors found multiple medication cups containing loose tablets and capsules, each labeled with resident names, stored in the top drawers of medication carts. These medications had been removed from their original packaging in advance of administration, contrary to facility policy and federal regulations. Interviews with nursing staff revealed that medications were routinely prepared ahead of scheduled administration times. One RN admitted to removing medications from their original packaging and placing them in labeled cups to expedite the medication pass process, acknowledging awareness that this practice was not permitted. Another RN stated that they typically prepared all medications for the day in advance and stored them in the medication cart, further confirming that this was a common practice among staff. Facility policies reviewed by surveyors clearly stated that medications must not be prepared in advance and must remain in their original containers until administration, with any removed but unadministered medications to be destroyed per policy. The Director of Nursing confirmed that staff had been repeatedly instructed not to remove medications from their packaging ahead of time, indicating that the staff were aware of the correct procedures but did not follow them. The deficiency was identified through direct observation, staff interviews, and review of medication administration records for the affected residents.