Improper Labeling and Storage of Medications and Nutritional Supplements
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications and biologicals during review of multiple medication and treatment carts and medication rooms. The facility’s own Storage of Medication policy required medications and biologicals to be stored safely, securely, and properly per manufacturer or supplier recommendations, to be kept in pharmacy-labeled containers, and for opened multi-dose preparations to be dated when first used. Despite this, an opened, undated Lispro insulin pen was found in the top drawer of a nurse medication cart, and the nurse present stated it should have been dated once opened but did not know who had opened or administered it. On the same hall’s treatment cart, an open tube of triamcinolone 0.1% cream was found without a cap, and the nurse acknowledged the medication should have had a cap but reported the cap was lost. Additional observations showed an opened Breo Ellipta 200 mcg/25 mcg inhaler sitting on a medication room countertop without any label identifying the resident to whom it belonged. In one treatment cart, a bottle of Nitroglycerin 0.4 mg was present without a label indicating the resident’s name or expiration date, and the LPN using the cart stated they did not know who the medication belonged to. Another medication cart contained a second bottle of Nitroglycerin 0.4 mg with no identifying name, as well as several cartons of Ensure Plus, one of which was open and not stored on ice or refrigerated, contrary to manufacturer instructions that opened Ensure should be refrigerated. The CMT using that cart stated they did not know who the Nitroglycerin belonged to and confirmed they had opened the Ensure that day.
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