Failure to Properly Label and Store Medications and Maintain Temperature Logs
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. One resident with multiple diagnoses, including diabetes and heart disease, was observed receiving an insulin injection and being offered nine oral medications in a cup. The resident declined to take the medications immediately, requesting to take them after breakfast. The LPN left the medication cup on the overbed table and exited the room, leaving the medications unattended. The resident confirmed that staff routinely left medications for her to take later, but there was no physician order, assessment, or care plan authorizing self-administration of medication for this resident. Additionally, a medication cart inspection revealed an unlabeled medication cup containing several pills intended for another resident with severe cognitive impairment. The LPN could not identify the medications or explain the lack of labeling. Furthermore, review of a medication refrigerator's temperature log showed missing entries for several days, and the infection preventionist could not account for the omissions, despite being responsible for daily review. These actions and omissions demonstrate failures in medication labeling, storage, and documentation practices.