Unsecured Medications and Improper Storage of DuoNeb Solution
Penalty
Summary
Surveyors observed that two medication carts (100 and 200 Hall) contained numerous loose and unsecured pills of various shapes, sizes, and colors in the bottom drawers. Medication Aides interviewed during the observations acknowledged that it was their responsibility to keep the carts clean and orderly, but there was inconsistency in their understanding and execution of this duty. The Unit Manager and DON also confirmed that maintaining clean and orderly medication carts was expected of the staff, with the DON noting that an extra nurse had been assigned to clean the carts during a recent shift. Additionally, the 200 Hall medication cart was found to have five DuoNeb inhalation vials stored loosely in a plastic cup, not in their original foil packaging, and without any indication of the date they were removed from the foil pack. Manufacturer guidelines require that DuoNeb vials be stored in the foil pouch to protect from light and be used within seven days of opening. Staff interviews revealed a lack of knowledge regarding proper storage and labeling of the DuoNeb solution, with both the nurse and Unit Manager stating that the vials should be dated and kept in the foil pouch, but this was not being done.