Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
The facility failed to ensure the safe, secure, and orderly storage of medications in both a medication cart and a medication storage room. In one instance, a medication cart contained Alka-Seltzer, melatonin, and Dulcolax in an original box with a resident's name handwritten on it, but without any labeling indicating the ordered dosage, route, frequency of administration, or prescriber name. The medications had been brought in by the resident's family without a physician's order, and there was no documentation in the resident's medical record regarding the receipt of these medications or physician notification. The resident's physician orders did not include these medications, and nursing progress notes lacked any mention of the family's action or subsequent staff response. Additionally, the medication storage refrigerator in a medication storage room was found to contain both resident beverages and medications, with a temperature log that was not consistently completed as required by facility policy. Several shifts had missing temperature documentation, despite the policy stating that temperature checks must be completed each shift. Staff interviews confirmed that the required procedures for labeling, physician orders, and temperature monitoring were not followed, and facility policies were provided that outlined these requirements.