Improper Medication Labeling, Storage, and Administration
Penalty
Summary
Surveyors identified multiple failures related to the storage, labeling, and administration of medications and creams within the facility. During wound care for a resident with severe cognitive impairment and multiple diagnoses, a registered nurse used a tub of silver sulfadiazine cream that was not labeled with a resident's name, stating she did not know who it belonged to but used it because she could not locate the correct cream. In another instance, the same nurse used silver sulfadiazine cream labeled for a different resident, which was also expired, for a resident with intact cognition and chronic wounds. The nurse admitted to sometimes using other residents' supplies if the correct ones could not be found and acknowledged that expired cream should not have been used. Additionally, surveyors observed several instances where medication and treatment carts were left unlocked and unattended in various hallways, with medications and creams left on top of the carts. In each case, no nurse was present in the area, and only certified nursing assistants were observed nearby. The nurse later stated that she usually locks the medication cart but sometimes forgets. The Director of Nursing confirmed that medication and treatment carts should be locked when unattended and that medications or creams should not be borrowed from other residents or used past their expiration date. Facility pharmacy policies require that all medications be labeled with the resident's name and expiration date, and that medication carts remain locked and inaccessible when not in use. The facility census at the time documented 73 residents who could potentially be affected by these practices. The survey findings were based on direct observation, staff interviews, and review of medical records and facility policies.