F0658

E

Medication Storage, Controlled Substance Documentation, and Enteral Feeding Order Communication Failures

Elmwood Park, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in medication storage, labeling, pharmacy services, and documentation, as well as failure to document and communicate a significant change in a resident’s enteral nutrition order. Surveyors observed numerous open insulin vials and pens on multiple medication carts without required open dates or beyond-use dates, including products for residents who had been discharged or were deceased. Several insulin vials and pens had stickers indicating “Do Not Use After” dates that had already passed, yet remained in the active medication drawers. An albuterol inhaler and several insulin products were found on the carts without pharmacy labels or resident names, and 24 loose pills were scattered in the top drawers of one cart. An expired stock bottle of Geri-Dryl liquid allergy relief was also stored with active medications. Staff interviewed on the units acknowledged that these medications were expired, lacked open dates, or were unlabeled and stated they should not be in use.

Record review showed that some of the insulin products belonged to residents who had been discharged or had died weeks earlier, and those medications had not been removed from the active supply or returned to the pharmacy. Current physician orders for several residents confirmed ongoing insulin therapy, yet the corresponding insulin vials or pens on the carts were either expired or missing required dating. Pharmacy and facility policies required that multidose injectable vials be dated upon opening, that shortened expiration dates be applied and observed, that all medications be stored in containers with pharmacy labels, and that expired medications be removed from active stock and destroyed. The DON confirmed that insulin should be dated when opened, discarded after the appropriate time frame, and that medications without labels should not be used. Despite these policies, surveyors found expired, undated, unlabeled, and stock medications commingled with active medications on multiple carts.

Additional deficiencies were identified in controlled substance documentation and handling. On several medication carts, controlled substance count sheets had multiple missing nurse initials for shift-to-shift counts on various dates. For several residents, the number of controlled medication doses documented as remaining on the monitoring/control records did not match the actual blister card counts, and nurses stated they had administered doses but had not yet signed them out. One resident’s oxycodone blister card had the original pharmacy label name blacked out and the resident’s name handwritten in marker, and the controlled medication was being documented on a handwritten sheet of copy paper instead of an individual controlled substance record. Facility and pharmacy policies required that each controlled dose be recorded at the time of administration on both the MAR and the controlled substance count sheet, that shift counts be completed and signed by oncoming and off-going nurses, and that controlled medications be dispensed with and tracked on individual controlled drug records. The DON stated it was not appropriate to document controlled counts on blank copy paper and that each controlled medication should have a proper count sheet.

The deficiency also includes failure to ensure professional standards in documenting and communicating changes in a resident’s diet order. One resident with anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status was care planned as NPO and dependent on enteral feeding for all nutrition needs. The resident previously had an order for continuous tube feeding with 2 CalHN, with a substitution order for Jevity 1.5 if needed, but this feeding order was discontinued. At the time of review, the resident had no active G-tube feeding order, only water flush and medication orders. The dietitian reported that she last saw the resident while on G-tube feeding and hydration therapy and stated she was not notified that the feeding had been stopped. The DON stated that hospice orders should be clarified by the floor nurse, who should verify with the physician, notify the dietitian, and document the order in the record. The LPN who received the order to discontinue feeding stated he simply stopped the feeding, did not document the change in the resident’s record, did not write a progress note, and did not notify the physician or dietitian, despite job descriptions requiring nurses to document nursing care and pertinent data according to facility policies and procedures.