Improper storage and labeling of IV supplies were observed in multiple medication rooms and in a resident’s room. A resident receiving IV meds had pharmacy-labeled normal saline flushes hanging from the IV pole in the room, while other saline syringes were stored as house stock in medication room drawers, and additional IV meds and unlabeled IV tubing and caps were found in a first-floor medication room. Staff stated resident supplies were being placed together and used for other residents, and saline flushes were also used for wound care.
Medication carts were not maintained in a clean and sanitary manner in 4 of 4 carts observed. Surveyors found loose pills and/or blister pack back covers in the bottom drawer of each cart, and the LPNs present said they were not aware of the debris. The DNS stated she was not aware the carts were not being cleaned, and the facility policy required drugs and biologicals to be stored in a safe, secure, orderly manner with medication storage and preparation areas kept clean, safe, and sanitary.
Improper Storage and Labeling of Controlled Medications: The facility failed to store controlled substances under double lock and failed to keep medications properly labeled and secured. Multiple controlled meds were found in the DNS office under only one lock, and the office door was open while unattended; the Administrator stated others had keys to the office. An LPN was also observed discarding medication cups from a med cart, and surveyors found an unlabeled cup of meds plus a recapped syringe containing an unidentified substance in the top drawer. The LPN could not identify the syringe contents or the refusal procedure, while an RN stated meds should not be pre-poured or kept in the top drawer.
A resident with type II DM and osteomyelitis had an order for Insulin Lispro via pen injector to be given per sliding scale. During a medication cart review, the resident’s insulin pen was found dated in a way that indicated it should have been discarded after 28 days, but MAR review showed it was administered on multiple occasions after that discard period. An LPN reported the insulin was used as needed and not recently, yet documentation showed administrations beyond the allowed timeframe, contrary to facility policy requiring Humalog (Lispro) insulin to be discarded within 28 days.
Medication Storage and Labeling Deficiencies: An RN found torn labels on resident-specific chlorhexidine bottles in a med room, and a locked narcotics box in the med refrigerator was not permanently affixed. In another med room, food items for residents were stored with medications, including sandwiches, packaged snacks, and an open cookie package, while a mini refrigerator used for narcotics was also not permanently affixed and held morphine and lorazepam. Staff stated they were unsure why some items were stored in the med rooms instead of the nourishment area.
Opened medications in multiple medication carts and medication rooms were found without open dates or expiration dates. An LPN on one cart and another LPN on a second cart acknowledged that opened meds should be labeled per policy but had not been doing so, and the DON also found unlabeled opened Humalog, acetylcysteine, Tubersol, and azelastine ophthalmic solution in the med rooms.
Expired medications were found in active circulation in the East med cart, including Methocarbamol, Hycosamine, and liquid Lorazepam. The Lorazepam was supposed to be refrigerated but was not, and it also lacked a corresponding white CSDR for administration documentation. An LPN, RN supervisor, and DNS all confirmed that expired meds should be removed, liquid Lorazepam should be refrigerated, and controlled substances should have a sign-off sheet.
Expired medications and unlabeled multi-use vials were found on medication carts. An LPN observed a bottle with no expiration date, another bottle opened after its expiration date, four Lidocaine 1% vials without opened dates, and an expired resident-specific Meclizine bubble pack with tablets remaining. Staff interviews confirmed that nurses were responsible for checking expiration dates, labeling opened vials, and removing expired or no-longer-prescribed medications from circulation.
Surveyors found that medications were left unattended at the bedsides of four residents, including while some were asleep, without proper physician orders for self-administration. An LPN left medication cups at the bedside for multiple residents, some of whom did not have authorization to self-administer, and in one case, a medication not approved for bedside use was present. Nursing staff and the DON confirmed that facility policy was not followed, resulting in unsecured medications and noncompliance with medication administration protocols.
Unsecured Medication Cart and Medication Room Keys: A DNS handed a set of keys to an RN, who used them to open the med cart and med room on a dementia unit. After the observation and narcotic count, the RN placed the keys in a plastic bin on top of the nurse's station desk. The DNS stated the keys should have remained on the nurse's person for the entire shift and then been handed to the oncoming nurse after report.
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