Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications and biologicals. On one occasion, a medication cart on the 500 hall was observed unlocked and unattended while the responsible LVN was at the other end of the hall. Additionally, both the 400-hall and 500-hall medication carts contained loose pills not secured in their original packaging, and the 500-hall cart had a bottle of glucose control solution that was opened but not labeled with the date it was first used, despite manufacturer instructions to discard after three months of opening. Further observations in the medication storage room revealed a large bag containing 100 individually wrapped ondansetron tablets without any prescription or resident label. The 500-hall medication cart also contained two unopened, unlabeled packages of Budesonide, a prescription medication, and an unlabeled blue pill. Interviews with nursing staff, the ADON, DON, and ADM confirmed that all prescription medications are required to have proper labeling, and that medication carts and storage areas should be kept locked and free of loose or unlabeled medications. Staff acknowledged that failure to follow these procedures could result in residents missing doses or receiving medications not intended for them. Facility policy review indicated that drugs and biologicals must be stored in their original packaging, labeled correctly, and kept in locked compartments when not in use. Only the issuing pharmacy is authorized to transfer medications between containers, and nursing staff are responsible for maintaining clean and secure medication storage areas. The observed failures to adhere to these policies were confirmed through staff interviews and direct observation.