Improper Medication Storage, Labeling, and Security
Penalty
Summary
The deficiency involves failure to ensure medications and medical supplies were properly stored, secured, and labeled according to professional standards and facility policy. In the medication room, surveyors observed multiple expired medical supplies, including respiratory infection test swabs, a wound culture, urinary catheter drainage bags, self-catheterization kits, female straight catheters, and several emergency airway and oxygen delivery items stored in the code box. Staff reported the code box had been used the previous day on a resident. The LPN/DON in training stated that overnight nurses were responsible for checking outdates during downtime and that a medication aide checked weekly, and acknowledged that expired items should have been removed and that their sterility and function could not be guaranteed if used. On two medication carts, surveyors found multiple insulin pens and inhalers that were opened or in use but not dated, including insulin pens for three residents and inhalers for five residents, as well as two opened glucose test strip bottles that were not dated. The LPN/DON in training stated insulin pens should not be used past expiration and that insulin pens and inhalers were expected to be dated once opened, and that carts were to be checked weekly and by night nurses. Surveyors also observed two separate instances where medication carts were left unlocked and unattended in hallways, one with no staff nearby and another with a resident sitting in front of the cart, while the responsible RN and DON were in or approaching resident rooms. The DON initially stated she did not think insulin pens needed to be dated until used, but the consulting pharmacist stated insulin was to be dated once removed from the refrigerator. The facility’s Administration of Medication policy stated that medication carts should remain locked when the nurse is not in close proximity and that at least visual control must be maintained to prevent unauthorized access.
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