Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications. One medication cart was observed unlocked and unattended at a nursing station, with several residents and staff passing by. The lock on the cart was only partially engaged, allowing access to over-the-counter medications, respiratory inhalers, ear and eye medications, diabetic supplies, and a locked narcotic box. The nurse responsible for the cart admitted to not fully locking it to allow nurse aides access to blood pressure supplies, and both the Regional Nurse Consultant and Director of Nursing confirmed that the cart should have been completely locked when unattended. In a separate incident, an opened vial of Lispro insulin was found in a medication refrigerator without an open date, discard date, or legible resident information on the label. The manufacturer’s guidelines require the insulin to be discarded 28 days after opening, and both the unit manager and Director of Nursing acknowledged that the vial should have been properly labeled and not used for any resident. The vial was subsequently discarded after being identified as non-compliant. Additionally, locked black boxes used to store refrigerated controlled medications were found unsecured to permanent structures in two medication rooms. These black boxes, although locked and kept in locked medication rooms, could be removed from the refrigerators, which themselves were not locked. Staff interviews confirmed that the black boxes were not secured to prevent removal, and the Director of Nursing stated that the controlled medications were considered secure due to being behind two locking mechanisms, despite the lack of physical attachment to a permanent structure.