Failure to Secure and Reconcile Emergency Medication Kit and Label Insulin
Penalty
Summary
The facility failed to maintain a secure and accurate system for managing medications in the emergency medication kit (E-Kit). During an inspection, the E-Kit was found unsecured on the medication room counter, lacking the required inventory list. Staff were unable to locate the inventory sheet, and it was confirmed by multiple nurses that the E-Kit should be secured with a zip tie and that an inventory list should be present inside the kit. Additionally, the staff did not consistently check to ensure the E-Kit was locked after use. An audit revealed missing medications, including vials of Haldol, lidocaine, and ampules of Phenergan, and there was no system in place for reconciling the medications removed from the E-Kit. Furthermore, the facility failed to properly label and date a resident's Insulin aspart pen, which is necessary for accurate medication administration and billing. The pharmacist delivered the E-Kit unlocked and provided an inventory list, but did not supply a reconciliation sheet for tracking medication usage. The facility's policy required the E-Kit to be kept locked, with an inventory list posted, and for record keeping to be in accordance with state pharmacy regulations. These lapses in medication management and record keeping placed residents at risk for inaccurate billing and potential medication errors.