Improper Medication Labeling, Dating, and Storage in Medication Room and Cart
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly labeled, dated, and stored in accordance with facility policy and professional standards in both the medication room and a medication cart. In the medication room, surveyors observed a bottle of liquid lorazepam in the refrigerator with an illegible label on both the bottle and box, and the LPN present was unsure whether it should be refrigerated. A vial of tuberculin purified protein derivative was found with an open date of 11/24/25, and the LPN did not know how long it remained usable after opening. A Hepatitis B vaccine syringe with an expiration date of 7/7/25 was also stored in the refrigerator, and the LPN acknowledged it should not have been there. A metal box containing insulin and narcotics from the pharmacy was found in the refrigerator; it was locked but not permanently affixed, and staff stated the narcotics could not be moved to the refrigerator’s lock box due to pharmacy key and assignment issues. The DON later confirmed the narcotics box should have been permanently attached to the refrigerator. In the west hall medication cart, surveyors found multiple loose, unlabeled pills in drawers, including three small round white pills and several identified tablets (duloxetine, Lasix, atorvastatin in multiple strengths, divalproex, pantoprazole, and quetiapine), and the LPN acknowledged these loose pills should not have been in the cart. A bottle of Evencare ProView glucose test strips in use for a resident’s blood sugar check lacked an open date, and the RN using them stated the bottle should have had an open date but was unsure how long the strips were good after opening, despite the operator’s manual specifying dating and discard timeframes. Additionally, an unattended medication cart was observed near the nurses’ station with a round white pill on the floor nearby; the LPN later stated she had dropped the medication earlier, could not find it, and admitted she should have moved the cart to locate and destroy the medication but had not done so.
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