Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals in multiple medication rooms and carts, as evidenced by observations and staff interviews. Specifically, expired and undated insulin vials and pens were found in two medication carts, with several items marked with opened dates well beyond the recommended 28-day usage period. Additionally, some insulin products were missing required opened and expiration dates. Staff confirmed that these items were expired at the time of observation. Further deficiencies were identified in three medication rooms, where expired medications, supplements, and medical supplies were found. Items such as expired fish oil, zinc, vitamin C, B12, iron, probiotics, IV tubing, and blood collection sets were observed. Some items were also undated, and staff interviews confirmed the expired status of these products. The facility's policies require medications to be stored according to manufacturer recommendations and for insulin to be dated upon opening, but these procedures were not followed. The facility's consultant pharmacist is responsible for routine inspections to identify and destroy discontinued, outdated, or deteriorated medications, but the presence of expired and improperly labeled items indicates that these inspections were either not conducted as required or were ineffective. The Nursing Home Administrator and the Director of Nursing confirmed the failure to properly store medications and biologicals in the affected medication rooms.
Plan Of Correction
During the survey, all medication and supplies that were expired were removed from med carts and supply rooms. All insulins in all medication carts and supplies in supply rooms will be checked for expiration dates and removed if expired. The Director of Nursing or designee will educate licensed nurses on the protocol for insulin dating and supply expiration dates. The Director of Nursing or designee will audit insulin dates and supply expiration dates weekly, three times, and monthly, two times. Results will be turned into the monthly Quality Assurance meeting.