Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. The medication refrigerator lacked temperature documentation for numerous days across several months, specifically missing records for 15 days in January, 17 days in February, 24 days in March, 15 days in April, and 12 days in May. Additionally, an unlocked treatment cart was found containing scissors and insulin, including a Humalog insulin pen that had been opened on 04/23/25 and was still present after its discard date of 05/20/25. A Lantus insulin pen was also found opened but not dated. Interviews with nursing staff and administrative personnel confirmed that the facility's policy required daily documentation of refrigerator temperatures, dating of insulin pens upon opening, and discarding insulin after expiration. Staff also acknowledged that medication and treatment carts should be locked when unattended. The facility's policies further specified that medications requiring refrigeration should be kept within a specific temperature range and that expired medications should be promptly removed and disposed of. These observations and staff statements indicate that the facility did not consistently follow its own medication storage and labeling protocols.