Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications and biologicals. In the Tea Garden Unit's nourishment pantry freezer, an opened package of sterile glycerine swabs was found without a date indicating when it was opened or how long the swabs could safely be used. The packaging was intended for single-use sterility, and the lack of dating did not comply with the facility's policy for recording the date opened and expiration for such items. Additionally, on a medication cart, a steroid inhaler was found without a box, unlabeled, and with no resident name, while another inhaler was opened without an open or discard date. Staff interviews confirmed that medications should be labeled with the resident's name and dated to ensure safety and prevent errors. Further review of the narcotic logbook on the same medication cart revealed five instances in May where nurses failed to sign the logbook to confirm the narcotic count during shift changes. Staff acknowledged that signatures were missing and that it was expected practice to reconcile and sign the narcotic logbook at each shift change to ensure accuracy and prevent drug diversion. These findings demonstrate lapses in following established medication storage, labeling, and documentation procedures.