Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, and security. An LPN left the 200-unit medication cart unlocked and unattended, contrary to the facility’s policy requiring carts to be locked when not in use. During a medication pass, a resident’s lispro insulin vial was observed not in its original box and without an opened date, bearing only a handwritten expiration/discard date. The same cart contained two Tresiba insulin pens labeled for another resident with dispensed dates but no corresponding medication order on that resident’s MAR. The resident receiving lispro insulin had an order for sliding scale insulin three times daily, and the manufacturer’s instructions require opened vials to be discarded after 28 days of use. Additional deficiencies were identified in the 300 Hall medication room and carts. In the medication refrigerator, opened house stock TB supplies and insulin from a discharged resident were found past their expiration dates, along with expired prefilled normal saline flush syringes. An opened container of 2 Cal Vanilla Medication Pass on top of the refrigerator lacked an expiration date. The 300 Hall medication cart contained approximately 50 loose pills scattered in a drawer. In the 200 Hall medication storage area, unidentified loose pills were found in a pill cup inside a cabinet, and multiple pill cups containing pre-popped, resident-specific medications (including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban) were observed lying on the counter. A PRN LPN working on the unit stated she was not aware of the facility’s policies or procedures regarding these practices.
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