Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified failures in the facility’s pharmaceutical services related to the labeling, storage, and cleanliness of medications on two medication carts. On the 200 hall medication cart, a bottle of milk of magnesia was found with dried drippings on the lid, and on the 300 hall medication cart, an empty bottle of Pro Stat liquid collagen with dried drippings was observed. Additionally, two open insulin pens for two residents were found undated in the 300 hall medication cart. According to interviews with the DON and nursing staff, insulin pens are required to be dated upon opening, and medication bottles should be cleaned before storage to prevent cross contamination, as per facility policy. The residents involved had significant medical needs, including diabetes mellitus managed with insulin therapy. One resident had a history of Type 2 diabetes mellitus with hyperglycemia and severe cognitive impairment, while another had Type 2 diabetes with complications and diabetic polyneuropathy, also with severe cognitive impairment. Physician orders for both residents included specific insulin regimens. The lack of dating on insulin pens and improper storage of medication bottles were confirmed through observation and staff interviews, indicating non-compliance with facility policy and accepted professional standards for medication management.