Improper Medication Labeling and Storage
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and facility policy. Observations revealed multiple instances of insulin vials and pens that were opened and undated, as well as insulin pens lacking resident identification. Additionally, a bottle of Tums was found opened, unlabeled, and expired in a medication cart. Controlled medications, specifically Tramadol tablets, were found improperly stored on a countertop rather than in a locked compartment. Staff interviews confirmed that these practices were inconsistent with facility policy, which requires proper labeling, dating, and secure storage of all medications, including the use of double locks for controlled substances. Further observations showed that during medication administration, staff left medications unattended on top of medication carts in areas accessible to residents and staff. This included opened insulin pens, pre-filled insulin syringes, and cups containing unidentified medications. In several instances, staff walked away from the medication cart, leaving medications exposed and unsecured in dining rooms and hallways. Staff interviews acknowledged that medications should not be left unattended and should be properly stored inside locked carts or storage rooms at all times. The facility's own policies require that all medications be stored securely, labeled with the date opened, and identified with the resident's name. Staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), the Director of Nursing (DON), and the administrator, confirmed their understanding of these requirements during interviews. However, the observed practices did not align with these policies, resulting in medications being improperly labeled, stored, and left unattended during administration.