Improper Medication Storage, Labeling, and Temperature Control on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely, properly labeled, and maintained at appropriate temperatures in accordance with facility policy and professional standards. On one medication cart, surveyors observed personal items including two individually wrapped cupcakes, an earring, and a personal fan stored on the cart. In the same area’s medication room, a mini refrigerator containing a variety of medications for multiple residents was found unplugged, with the temperature gauge reading 65°F and a high temperature alarm displayed. Temperature readings taken over several minutes showed the refrigerator temperature remained outside the facility’s required 36°F to 46°F range, and the temperature log showed no documented checks for several consecutive days. On another hall’s nurse cart, surveyors observed non-medication items such as dry erase markers in the top drawer and multiple medications that were not properly labeled. These included insulin pens without open dates and with resident names handwritten only on the caps, and topical creams (Boudreaux’s Butt Paste and Desitin) without open dates or resident names. On the corresponding CMT cart, a half white circular pill identified as trazodone 50 mg remained in a pill cutter, indicating a loose, unidentified dose not stored in its original packaging. Staff interviews revealed that night shift staff were responsible for checking refrigerator temperatures, but the LPN on duty did not confirm that the refrigerator had been checked and was unfamiliar with the facility’s policy. On the Med A Hall nurse cart, surveyors found 13 insulin pens with only handwritten names and no patient labels, as well as topical medications such as betamethasone valerate ointment and Aspercreme without open dates. A biohazard bag on the cart contained 24 expired urine tubes and urine culture tubes, and a plastic bag labeled for refrigeration contained two prefilled syringes of glatopa 40 mg/mL that were not in a refrigerator. On the Med A Hall CMT cart, a blister pack of loperamide 2 mg and a blister pack of cetirizine with four remaining pills were present without patient labels or open dates, and a loose oval white pill was also observed. During interview, the DON confirmed that insulin pens should have proper patient labels and that resident names should not be handwritten on caps, and stated that when a resident is discharged, the nurse is primarily responsible for removing and destroying medications no longer in use.
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