An expired bottle of Colace gel tablets was found in the South Hall med cart during an audit with an LPN present. The facility’s policy requires checking the expiration or beyond use date before administering meds, but the LPN stated the bottle should have been discarded and had not been; the DON also stated it should have been removed from the cart.
A facility failed to properly discard a completed antidepressant order found on a med cart. An RN found a blister pack of sertraline HCl 25 mg with tablets remaining for a resident with depression and anxiety, even though the 30-day order had already ended. The RN and CNO stated completed or expired meds should be removed from the cart promptly, but the medication had remained there for over two months past the completion date.
Unsecured medications were found in a resident’s room and an unlocked treatment cart was observed unattended. A resident with moderate cognitive impairment had Systane eye drops on the bedside table, but the record did not show an order for the drops or a self-administration assessment. An RN stated she forgot to lock the treatment cart, and the CNO confirmed the cart should have been locked when unattended.
Expired liquid lorazepam was found in a medication cart during a surveyor review, and an RN acknowledged the medication was expired. The facility policy required expired or discontinued meds to be removed promptly and disposed of per policy and DEA guidelines, but the medication remained in storage for A resident.
Medication storage and security were not maintained when an open bottle of Ativan for a resident was found in an unlocked medication refrigerator on top of the narcotic lock box, and a discontinued medication had not been removed promptly. In a separate observation, an East Hall medication cart was left unlocked and unattended until an LPN returned and locked it; the DON and LPN both stated the cart should not have been left unsecured.
Surveyors found multiple expired medications, including various insulin products, Trulicity injection pens, and a large bottle of Gabapentin solution, stored in a medication room refrigerator and still available for use. The MDS coordinator confirmed the drugs were expired. The DON reported that no one had been specifically assigned to check the refrigerator for expired medications, while an LPN stated she only reviewed medication carts and did not check refrigerated stock. Facility policies required checking expiration/beyond-use dates before administration, dating multi-dose containers when opened, discarding them within specified time frames, and returning or destroying outdated medications, but these procedures were not followed for the medications in the refrigerator.
A medication storage deficiency occurred when a medication cart on one nursing unit was left unlocked and unattended. An LPN believed the cart’s timer-based lock had engaged when stepping away, but when attempting to demonstrate that it was locked, a drawer opened, confirming it was unsecured. The LPN reported not knowing the exact timing of the cart’s automatic lock and acknowledged not double-checking its status. The CRN later stated that medication carts are required to be locked whenever staff leave them unattended.
Surveyors identified multiple failures in medication storage and control, including unsecured bedside medications and improperly stored controlled drugs. One resident with a history of blood clots and depression had zinc oxide and antifungal cream left at the bedside without an IDT self-administration assessment or a physician order to keep medications at the bedside. Another resident with CHF and diabetes had Biofreeze cream at the bedside, which staff applied, but there was no provider order or care plan for its use, and the ADON reported the family likely supplied it. Additionally, Lorazepam nasal spray, a Schedule IV controlled medication, was found in clear plastic cups on a medication refrigerator shelf instead of in a separately locked, permanently affixed compartment, and a medication cart on one hall was observed left unattended, unlocked, with a drawer open.
Surveyors found a medication cart unlocked and unattended in a resident care hallway, despite facility policy requiring medications to be stored safely, securely, and accessible only to authorized personnel. An LPN later confirmed she had left the cart unlocked and acknowledged it should have been locked, creating a situation in which medications could be accessed by individuals for whom they were not prescribed.
Surveyors identified multiple failures in medication labeling, dating, and storage, including an illegible lorazepam label in the refrigerator, an opened tuberculin vial and a Hepatitis B vaccine syringe improperly stored, and a non–permanently affixed locked box containing insulin and narcotics in the medication refrigerator. In a medication cart, loose unlabeled pills and various identified tablets were found in drawers, and a bottle of glucose test strips in use lacked an open date despite manufacturer instructions. An unattended medication cart was also observed with a pill on the floor nearby, which an LPN later admitted she had dropped and not properly located and destroyed.
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