Failure to Date Opened DuoNeb Inhalation Solution on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices involving DuoNeb inhalation solution on one of three medication carts reviewed (the C and D cart). Manufacturer guidelines for DuoNeb require that, after opening the foil pouch, individual vials be used within 14 days. During an observation of the C and D medication cart with a nurse, surveyors found an open, undated box of DuoNeb solutions stored in the cart drawer and available for use, with a delivery date on the box of 12/23/25. The nurse interviewed stated that the box should be dated when opened and that vials not used within 7 days should be discarded. In a separate interview, the DON stated that nurses are expected to check medication carts daily and that ensuring DuoNeb solutions are dated is part of those daily checks, and that the nurse who opens the box is expected to date it. This failure to date the opened box of DuoNeb solution, despite manufacturer instructions and facility expectations for daily cart checks and dating by the opening nurse, led to the cited deficiency in ensuring drugs and biologicals are labeled in accordance with accepted professional principles.
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