Unsecured Medication Cart and Improper Medication Labeling
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended outside a resident's room. The nurse responsible for the cart was inside the room and not visible from the hallway, leaving the cart accessible. During this time, a surveyor was able to open the top drawer of the cart and found an opened 20 ml vial of sterile water without a date indicating when it was opened. Additionally, several insulin pens were found in the cart, some of which were opened without being dated, and one insulin pen had a broken seal and no resident name. Another insulin pen was opened and dated, but still present beyond the recommended usage period. According to the National Institute of Health, sterile water vials should be discarded no later than 4 hours after being punctured, and insulin pens should be dated when opened and discarded 28 days after opening, per manufacturer instructions. The observed failure to properly label and store medications and biologicals, as well as to secure the medication cart, constituted a deficiency in compliance with accepted professional principles for medication management.