Improper Medication Labeling and Storage on Medication Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on one of the medication carts were not labeled and stored according to professional standards. Specifically, a blister pack containing tramadol for a resident had a broken seal with the pill still inside, and an insulin pen for another resident was in use without an open date indicated. The nurse responsible for the cart did not check blister packs during the narcotic count at shift change and was unaware of when or how the blister pack seal was broken. The nurse also administered insulin without verifying or documenting the open date on the pen, which is necessary to ensure the medication's effectiveness within its shelf life. Interviews with the nurse and the DON confirmed that staff are expected to check for broken seals and to date insulin pens when opened, but these procedures were not followed. The facility's policy requires immediate removal and disposal of medications in compromised containers and mandates dating of certain medications upon opening. The DON acknowledged that keeping a pill in a broken blister pack is not acceptable and that insulin pens must be dated to track expiration. The pharmacy consultant and ADONs are supposed to perform regular checks, but these lapses were still found during the survey.