Deficient Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medication storage areas. During observation and interviews, it was found that a resident had over-the-counter (OTC) eyedrops stored unsecured at her bedside and self-administered them without having been trained or authorized to do so. The resident, who had a history of Parkinsonism, anxiety disorder, and mild dementia, reported that she had kept the eyedrops in her room since admission and was unaware that this was not permitted. Facility staff, including the DON, were not aware of the unauthorized medication storage until it was identified by surveyors. Additionally, inspection of a medication cart revealed several deficiencies in medication storage and labeling. The 200 Hall Med Aide Cart contained an expired, open bottle of Aspirin, an open bottle of liquid protein supplement without an open date, four loose pills of varying types, and an open bottle of Fish Oil with no visible expiration date. Staff interviews confirmed that nursing staff are expected to check carts daily for expired or inappropriately labeled medications, and that multidose containers must be labeled with the date opened. These expectations were not met, as evidenced by the presence of expired and improperly labeled medications, as well as loose pills in the cart. Facility policy requires that all drugs and biologicals be stored in locked compartments under proper temperature controls and that medications be kept in their original containers with appropriate labeling. The observed failures included unsecured resident medications, expired and unlabeled items in the medication cart, and lack of staff awareness or adherence to medication storage protocols. These actions and inactions led to the identified deficiencies in medication storage and security.