Failure to Label, Store, and Secure Medications as Required
Penalty
Summary
Surveyors observed that multi-dose medication vials in both the North and South Hall medication storage rooms were not labeled with open dates as required. Specifically, an opened vial of Tuberculin Purified Protein Derivative in the North Hall refrigerator and an opened vial of Acetylcysteine Solution in the South Hall medication room were found without open dates. The Acetylcysteine vial also had an illegible pharmacy label and was not stored in the refrigerator as recommended by the manufacturer. Interviews with the DON and Administrator confirmed that vials should be labeled with open dates and stored according to manufacturer instructions, but these procedures were not followed. Additionally, during medication administration, a nurse left medication cards containing doses of midodrine and gabapentin for two residents unsecured on top of the medication cart while attending to a resident behind a privacy curtain, leaving the medications unattended and out of sight. The nurse acknowledged being nervous during observation and did not realize the medications were left out until returning to the cart. Both the DON and Administrator stated that medications should not be left unattended during administration.