Failure to Properly Label, Store, and Discard Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were properly labeled and expired or discontinued medications were discarded as required. On two medication carts and in one medication room, multiple insulin pens and vials lacked labels identifying the resident, dosage, or open dates, making it impossible to verify their intended use or efficacy. Several insulin pens and vials were found past the manufacturer’s recommended storage period at room temperature, and a bottle of potassium tablets was found expired by 60 days. Additionally, the narcotic drawer contained medications belonging to residents who had been discharged or whose orders had changed, including morphine, lorazepam, and oxycodone, which had not been destroyed or returned to the pharmacy. Staff interviews confirmed a lack of awareness regarding the ownership and status of some medications, as well as uncertainty about proper storage and expiration protocols. Staff acknowledged the presence of expired medications and those needing destruction or return, and indicated that medication room maintenance and rotation were the responsibility of night shift nurses. The facility’s own policy required medications to be labeled with expiration dates and to be separated and destroyed or returned if expired, contaminated, or no longer in use, but these procedures were not consistently followed.