Improper Storage and Labeling of Lorazepam on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals, specifically liquid Lorazepam, on three of five medication carts. Observations revealed that Lorazepam, which required refrigeration as indicated by pharmacy labels, was found on medication carts instead of being stored in a refrigerator. In one instance, a nurse acknowledged the medication should have been refrigerated and took steps to move it after being observed. Additionally, one medication box had a damaged and illegible label, making it impossible to verify the resident's name, dosage, or administration instructions. Interviews with facility staff, including the FNP, DON, ADM, ADON, and a nurse, confirmed that staff were aware of the requirements for proper medication storage and labeling, including the need to refrigerate certain medications and ensure labels were legible and complete. Despite this, staff could not provide reasons for the observed deficiencies, and it was noted that some medications were received from hospice in an improper condition. Staff also reported that medication cart audits were conducted, but these audits failed to identify the improperly stored and labeled Lorazepam. The facility's policy required that controlled substances needing refrigeration be stored in a locked box within the refrigerator and that all medication labels include specific identifying information. However, the observed practices did not align with these requirements, as medications requiring refrigeration were left on carts and at least one medication label was illegible. The pharmacy consultant was unaware of the improper storage and could not provide information on the potential negative outcomes of these deficiencies.