F0761

D

Improper Labeling of Glucose Control Solutions and Unlocked Medication Cart

Idaho Falls, Idaho Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to ensure biologicals were labeled when opened and to store medications in locked compartments as required by facility policy and manufacturer instructions. The facility’s policy on storage and expiration dating of medications and biologicals required that once any medication or biological package was opened, manufacturer guidelines for expiration dates be followed. The Assure Prism Blood Glucose Monitoring System QA/QC manual specified that when a control solution bottle is first opened, the discard date (date opened plus three months) must be recorded on the label. Surveyors observed one set of Assure Prism glucose test solutions (CSYF24BN and CSYM26AM) that were not dated when opened and had no expiration date written on the label. An RN stated she did not know how long the test solutions had been opened and used. Review of blood glucose testing logs showed these same solutions were documented as opened and used for testing over multiple months, and the Infection Preventionist confirmed they should be dated when opened and used only for three months.

The deficiency also includes failure to keep a medication cart locked when unattended, contrary to the facility’s General Dose Preparation and Medication Administration policy, which required medication carts to be locked when out of sight or unattended. Surveyors observed a Hall 2 medication cart left unlocked and unattended by the medication nurse. Shortly thereafter, an RN was seen pushing a Hoyer lift down the hall toward the medication room and stated the medication cart should have been locked when left unattended. The DON also stated the medication cart should have been locked when not attended by the nurse and acknowledged that it had not been.