Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to the improper storage and labeling of medications on the South Long Hall medication cart. During an observation, it was found that a registered nurse had pre-pulled morning medications for eight residents and placed them in individual medicine cups labeled with initials, storing them in the top drawer of the medication cart. The nurse admitted to pre-pulling the medications and acknowledged that this practice was not permitted. The Director of Nursing confirmed that medications should only be pulled at the time of administration and that pre-pulling is not allowed. The residents affected had a range of medical conditions, including diabetes, hypertension, chronic pain, dementia, epilepsy, and other chronic illnesses. Their care plans and physician orders required the administration of various medications, including controlled substances and medications for pain, blood pressure, anxiety, and other conditions. The medication administration records indicated that the medications were signed out as administered as ordered. However, the practice of pre-pulling and storing medications in cups outside of their original packaging and outside of locked compartments did not comply with accepted professional principles for medication storage and labeling. The deficiency was identified through record reviews, observations, and interviews with both the nurse involved and the Director of Nursing. The surveyors found that the medications for eight residents were not stored in accordance with regulations, as they were not kept in locked compartments and were not properly labeled. This practice affected eight out of 29 residents who received medications from the South Long Hall medication cart, in a facility with a census of 95.