Failure to Properly Store, Label, and Dispose of Medications
Penalty
Summary
Surveyor observations and staff interviews revealed multiple failures in the facility's medication management practices. On one occasion, a medicine cup containing a Tylenol tablet was left unattended on top of a medication cart in the hallway, with the Certified Medication Technician admitting to dispensing the medication and leaving it out instead of discarding it. Additional observations of medication carts found opened Lantus insulin pens and a Breo Ellipta inhaler without dates, as well as an expired Lantus insulin pen and an opened Active Liquid Protein container without a date, all contrary to manufacturer instructions and facility policy. Staff acknowledged these items were either expired or not properly dated when opened. Further deficiencies were identified in medication rooms, where surveyors found bottles of Kayexalate and a box of Lovenox injections prescribed for residents no longer on the unit, which had not been placed in the discarded medication bin as required. Refrigerators in medication rooms contained an opened Lispro insulin pen without a date and a bottle of Lorazepam Intensol that was expired. Staff interviews confirmed awareness that these medications were either expired, not dated, or should have been discarded, but had not been managed according to policy and professional standards.