Medication Labeling, Storage, and Removal Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication management practices. On several medication carts across different units, there were loose tablets and unidentified medications, including medicine cups with unknown substances and tablets without proper labeling or identification. Expired insulin pens were found on the carts, with labels indicating they should have been discarded 28 days after first use, but they remained accessible. Multi-use vials, such as an opened Haldol injection, were present without any indication of the date they were first accessed. Additionally, medication carts contained narcotic medication cards for residents who had been discharged from the facility, some for over a month or two, and these were not promptly removed from the carts. Interviews with nursing staff and the DON revealed that nurses were instructed not to remove empty or discontinued medication cards from the carts due to a previous drug diversion incident. The DON stated she checks and removes narcotics from the carts every other week, but a significant backlog of narcotic cards for discharged residents was still present, particularly on the 600 unit. Despite these issues, recent pharmacy consultant reports did not document any problems with medication carts or controlled substance logs. The observed failures included improper labeling, failure to date multi-use vials, not following expiration instructions, and inadequate storage and removal of controlled substances.