Deficient Medication Storage, Labeling, and Expired Supplies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and management of drugs and biologicals within the facility. Observations revealed that several opened medications and nutritional supplements, including bottles of PEG 335 Polyethylene Glycol, Med Plus nutritional drinks, and ReadyCare Thickened Orange Juice, were not labeled with the date they were opened. This made it impossible to determine their discard dates. Staff interviews confirmed that the facility's policy requires dating and initialing items upon opening, but this was not consistently followed. Additionally, expired supplies such as IV fluids and COVID-19 test kits were found in medication rooms, with staff acknowledging that these items should have been discarded once expired. Further observations uncovered loose, unlabeled, and unidentified medications in medication carts and drawers. These included capsules and tablets without any identifying information regarding the resident or the medication itself. In one instance, a half tablet was found in a medicine cup with only a handwritten note, and staff could not determine to whom it belonged or how long it had been there. Interviews with nursing staff and management indicated that regular checks of medication rooms and carts were expected, but these checks were not effectively ensuring compliance with storage and labeling policies. The facility's own policies, as reviewed by surveyors, require that all drugs and biologicals be stored in their original packaging, labeled with the date opened, and checked for expiration prior to use. Despite these policies, the survey found that both nursing and central supply staff failed to consistently check and remove expired or improperly labeled items. The responsibility for these checks was acknowledged by various staff members, including the DON and Executive Director, but lapses in practice led to the deficiencies observed.