Deficiencies in Medication Storage, Labeling, and Security
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals for four residents. For one resident with type 2 diabetes mellitus and end stage renal disease, an opened insulin vial was found without an open or expiration date. The responsible RN confirmed the vial was opened and subsequently labeled it during the observation. Another resident with diabetes had an insulin pen in the medication cart that was also missing an open or expiration date, and the LPN interviewed was unsure of the exact duration insulin remained viable after opening. This resident had already been discharged at the time of the observation. Additional deficiencies were observed with medications not being properly stored. A bubble pack of sucralfate for a resident with gastro-esophageal reflux and cyclical vomiting was found in the medication room sink with one tablet remaining. Similarly, compounded daptomycin vials for a resident with sepsis and pneumonia were also found in the medication room sink. The DON stated that medications should not be stored in the sink and explained that these were intended to be returned to the pharmacy, which collects unused medications twice daily. Surveyors also observed a medication cart left unlocked and unattended in a hallway. The DON and LPN confirmed that the cart should be locked when not attended, and the RN responsible for the cart stated she had left her keys with the LPN during her break but was unsure if the cart had been left unlocked. The DON reiterated that medication carts should always be locked when unattended and that no medications or resident information should be left exposed.