Unsecured Medications and Improper Storage of Latanoprost
Penalty
Summary
Surveyors identified that prescription-strength ammonium lactate lotion, antifungal powder, and betadine solution were found unsecured on a resident's bedside table. The resident, who had severe cognitive impairment and no active orders for these medications or treatments, was unable to self-administer medications. The items included a prescription lotion with a discard date, an antifungal powder prescribed to another resident, and an opened bottle of betadine solution. Staff interviews confirmed that there were no physician orders or documentation for these items, and that the resident did not have an order for self-administration. Nursing staff and the Director of Nursing acknowledged that these medications should have been stored in a locked cart and not left at the bedside. Additionally, during a medication storage audit, an unopened bottle of Latanoprost ophthalmic solution was found stored at room temperature in a medication cart, contrary to manufacturer guidelines requiring refrigeration until opened. An opened bottle of Latanoprost was also found in the cart without a date indicating when it was opened, making it unclear how long it had been stored at room temperature. Nursing staff were unable to provide information on how long the medications had been improperly stored or when the opened bottle was first used. Interviews with nursing staff and facility leadership confirmed that the facility's policy and manufacturer guidelines were not followed regarding the storage and dating of Latanoprost. The Director of Nursing and Administrator both stated that medications should be stored according to policy and manufacturer instructions, including proper dating and refrigeration, but these procedures were not adhered to in the instances observed.