Medication Storage, Expired Insulin, and Controlled Substance Accountability Deficiencies
Penalty
Summary
The facility failed to maintain proper medication management practices in several key areas. Observations revealed that the medication storage room consistently exceeded recommended temperature limits, with recorded temperatures ranging from 80 to 82 degrees over multiple days. Staff acknowledged the importance of maintaining appropriate temperatures to prevent medication degradation, but the issue persisted without resolution. Additionally, expired insulin pens and undated insulin vials were found on a medication cart, with one pen opened beyond the recommended 28-day use period and another lacking an open date. Staff confirmed the necessity of discarding expired insulin to ensure medication effectiveness. Further deficiencies were identified in the handling of controlled substances. An emergency kit containing injectable and oral Ativan was stored in the medication room, but staff interviews revealed that the Ativan was not being tracked or counted as required for narcotics. While the kit was verified as sealed with a pharmacy zip tie, staff admitted that the contents were not regularly accounted for, contrary to policy and best practices for controlled substance management. These lapses in medication storage, labeling, and accountability were directly observed and confirmed through staff interviews.