Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were stored in a safe and secure manner on two of five medication carts. On one cart, two expired ophthalmic drops were found, along with a nutritional supplement bottle that was soiled, stored in a bag with a crystallized substance, and had an expiration date that was no longer visible. Additionally, a loose, unlabeled pill and capsule were discovered in the medication drawer. The controlled substance record book on this cart had multiple pages that were torn, loose, and no longer secured within the binder, creating a risk for inaccurate or incomplete controlled substance accountability. On a second medication cart, another loose, unlabeled capsule was found in the medication drawer. Nurses interviewed during the survey were unable to identify the loose medications or determine which residents they were prescribed to. The facility's policy requires nurses to check all medications for expiration and deterioration before administration, maintain clean and organized medication carts, and complete daily audits to remove outdated, contaminated, or deteriorated medications. However, these procedures were not followed, as evidenced by the presence of expired medications, soiled supplements with unreadable expiration dates, and loose, unidentified pills. Interviews with nursing staff and facility leadership confirmed the findings, acknowledging that expired medications and supplements should not be administered and that loose, unidentified medications could result in residents not receiving their prescribed medications. The presence of unsecured pages in the controlled substance record book was also confirmed, with staff noting that this could result in medications not being administered properly or according to orders. The facility's expectations were reiterated by the administrator, who stated that nursing staff are responsible for ensuring expired medications are not present and that medication carts remain clean and free of loose pills.