Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of drugs and biologicals. On one medication cart, a multi-dose oral inhaler (Trelegy Ellipta) was found without an opened date, despite manufacturer instructions requiring it to be discarded six weeks after opening. Nursing staff interviewed were unaware of the missing date and had not checked the medication cart for expired medications that day. Additionally, expired medications were found on two wound treatment carts and in a medication storage room, including Biofreeze pain relief spray, Minerin cream, Potassium Chloride IV solution, Gentamicin vials, a Normal Saline syringe, and Lisinopril tablets. Staff interviewed were not aware of the expired medications and indicated that all nurses, as well as the Unit Manager, were responsible for checking expiration dates, but these checks had not been performed or were insufficient. Further, one wound treatment cart was observed to be unlocked and unattended, with no staff present and no clear accountability for who left it unsecured. Interviews with nursing staff revealed uncertainty about who was responsible for the unlocked cart and expired medications. The Director of Nursing confirmed that assigned nurses and the Unit Manager were responsible for ensuring medication carts and storage rooms were checked for expired medications and that all medications were properly labeled and secured. However, these responsibilities were not consistently fulfilled, resulting in expired and improperly labeled medications being accessible and a treatment cart left unlocked.