Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of medications on two medication carts. Specifically, insulin pens were found without resident name labels, with open and discard dates not properly documented, and in some cases, the discard date exceeded the recommended 28-day period. Additionally, a pill cup containing a loose, unidentified pill was found in a medication cart drawer without a resident name, after a nurse left it there when a resident declined to take the medication and the nurse was called away. Expired medications were not disposed of as required, and some medications may have been pulled from the emergency kit without appropriate labeling. Interviews with LPNs and the DON confirmed that these practices were not in accordance with facility policy or pharmacy guidelines, which require medications to be labeled with the resident's name, open and discard dates, and to be discarded if not administered or if expired. The DON stated that insulin pens are to be discarded within 28 days of opening and that medications not administered at the time of removal from the cart should be discarded. The observed deficiencies had the potential to result in medication errors and improper administration.