Improper Medication Storage, Labeling, and Disposal Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices during observations of medication carts and storage rooms. In one instance, two Tylenol tablets and a vitamin tablet were found stored in a medication cup inside a cart after a resident refused them, and the LPN stated that refused medications were discarded in a trash can. Additional issues included an open, undated insulin pen, loose pills, and individually packaged medications not labeled with resident names. Similar findings were observed in other medication carts, including loose tablets, opened and undated bottles of supplements, and expired medications belonging to discharged or deceased residents. Further observations in medication storage rooms revealed medications for discharged or expired residents stored in open pharmacy bags, as well as expired enteral feeding formula. The refrigerator temperature log for medication storage was missing signatures for several days, and the unit manager admitted to lapses in monitoring and documentation. Staff interviews confirmed inconsistent practices for disposing of medications, with some stating that medications were returned to the pharmacy, while others described crushing and flushing non-narcotics or using a drug buster for narcotics, often without clear documentation or adherence to policy. The facility's policies require proper labeling, dating, and secure storage of all medications, as well as appropriate disposal in accordance with state and federal regulations. However, staff interviews and direct observations demonstrated a lack of compliance with these requirements, including improper storage of loose and unlabeled medications, failure to date opened bottles, retention of expired medications, and inconsistent documentation of refrigerator temperatures.