Failure to Replace and Document Use of Emergency Medication Kits
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident by not properly managing emergency medication kits on two out of three units. During inspection, an opened insulin kit was found in the second-floor medication room refrigerator with some contents missing. There was no documentation indicating what had been removed, when it was removed, or who had removed the items. Additionally, there was no evidence that the kit had been reordered from the pharmacy for replacement. Staff interviewed were unable to confirm when the kit was accessed or if it had been reordered, despite facility policy requiring immediate reordering upon opening. A similar issue was observed on the third floor, where an intravenous (IV) emergency kit was found opened with some contents removed. Again, there was no documentation regarding the removal of items, and staff were unaware of when the kit was accessed or if it had been reordered. The facility's policy states that emergency kits should be exchanged or replenished by the pharmacy as needed, and staff interviews confirmed that kits should be reordered immediately after being opened. However, these procedures were not followed, resulting in a failure to meet the pharmaceutical needs of residents.