Improper Pre-Popping and Storage of Medications by Staff
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided, specifically in the dispensing and administration of medications by staff. Multiple instances were observed where medications were pre-popped from blister packs and placed into medication cups, which were then either left unattended in resident rooms or stored in medication carts prior to administration. On one occasion, five clear medication cups containing different residents' medications were found in a resident's room, with the medications intended for administration but apparently forgotten. Further observations revealed that staff, including LVNs and a medication aide, had pre-popped medications for multiple residents and stored them in labeled or unlabeled cups within medication carts. One LVN had 15 cups with different resident names and medications, while another had two cups with resident names written on the bottom. The medication aide had three cups with medications but no resident names. Staff members acknowledged during interviews that they were aware pre-popping medications was not permitted and that medications should not be dispensed prior to the time of administration. Record reviews confirmed that the facility's policy required medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and route before administration. The policy also stated that medications should not be left at the bedside or pre-prepared for later administration. These practices were not followed, as evidenced by the observations and staff admissions.