Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of drugs and biologicals. An unattended and unlocked medication cart was left facing the hallway for 13 minutes, during which time three staff members and a resident in a wheelchair passed by. The Unit Manager later acknowledged forgetting to lock the cart, and the DON confirmed that medication carts are expected to be locked when not in direct line of sight. Additionally, another medication cart was found to contain 11 loose, unsecured pills of various types, with both the nurse and DON stating that medication carts should be clean and free of loose pills. Further observations revealed expired over-the-counter medication (Vitamin B6) available for use in a medication storage room, which both the Unit Manager and DON agreed should not occur. On another medication cart, 20 vials of ipratropium bromide inhalation solution were found in an open foil package without a label or date opened, despite manufacturer instructions to discard the medication two weeks after opening. The nurse responsible was unaware of this requirement, and the DON stated that all medications should be labeled and dated when opened.