Failure to Properly Store, Label, and Dispose of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and facility policy. Multiple residents were found to have medications, including prescription inhalers, nasal sprays, and dietary supplements, stored at their bedside without proper physician orders or completed self-administration assessments. In several cases, residents self-administered these medications without documentation of an evaluation to determine their ability to do so safely, and without orders permitting bedside storage. Staff interviews confirmed that these practices were not in line with facility policy, which requires an assessment and physician order for self-administration and bedside storage of medications. Additionally, the facility did not properly manage the storage and disposal of expired medications and biologicals. Observations in the medication room revealed undated multiuse vials and opened nutritional supplements that were past their use-by or best-by dates. Expired medical supplies, such as normal saline bottles, a PICC line dressing kit, sterile water, and a humidifier adaptor, were found in crash carts on two different halls. Staff acknowledged that these items were expired and should have been discarded according to facility policy, which mandates the removal of outdated or deteriorated medications and supplies. The deficiencies were further evidenced by incomplete documentation, such as a blank self-administration assessment for one resident, and the lack of care plan documentation supporting independent medication storage. Staff interviews consistently indicated an expectation that medications should be locked and only accessible to residents with appropriate orders and assessments. The observed failures in medication storage, labeling, and disposal were not in accordance with the facility's own policies and placed residents at risk for receiving compromised or ineffective medications and supplies.