Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the storage and labeling of drugs and biologicals. During inspection, it was found that when the medication storage refrigerator temperature was recorded as out of range, there was no documentation that maintenance was notified, no record of temperature adjustment, and no evidence that the temperature was rechecked within the required timeframe. The maintenance logbook did not contain any entries regarding the incident, and the Assistant Director of Nursing confirmed the lack of documentation and follow-up. Additionally, temperature logs for medication storage rooms and refrigerators were found to have multiple missing entries for both May and June. In some cases, entire shifts lacked temperature checks, and on one occasion, two different temperatures were circled for the same day, making it impossible to determine the correct reading. The facility's policy requires daily temperature checks for storage rooms and twice-daily checks for refrigerators, but these were not consistently performed or documented. Further deficiencies were observed in the labeling of medications and supplies. An insulin pen for a resident was found in the medication cart without an open date or expiration date, making it impossible to verify its usability according to policy. Similarly, a blood glucose test strip container lacked an open date, contrary to manufacturer instructions and facility policy, which require such labeling to ensure the strips are used within their effective period. These lapses resulted in medications and supplies not being safely stored or tracked to ensure their integrity.