Improper Labeling of Insulin Pens: Two residents’ insulin pens were found on the insulin cart without the original pharmacy labels. Staff had handwritten pink labels with the residents’ names, but the names were not easily legible and no other resident-specific identifying information from the pharmacy labels was present. Facility policy and staff interviews confirmed that insulin pens should retain pharmacy labeling identifying the correct resident, medication, and dose.
Improper Storage of Refrigerated Medications: Medications in the North Hall med room refrigerator, including a COVID-19 vaccine, insulin pens, Ozempic, and TB serum, were stored in the refrigerator door rather than in a protected location. Staff interviews confirmed nursing was responsible for medication storage, and the LPN, DON, and Administrator all stated the door was not an appropriate storage area because of temperature fluctuations and light exposure that could affect medication effectiveness.
Medication storage and labeling were not maintained for two residents’ medications. An RN and KMA found eye drops without proper opened dates, an unopened insulin pen stored in a cart instead of the refrigerator, and two unopened vials of stock heparin kept in the same cart compartment as ophthalmic solutions. Staff and the contracted pharmacist confirmed that opened multi-use meds should be dated and that insulin and stock heparin had specific storage requirements.
Expired topical medications were found in the medication refrigerator for two residents. The products were labeled for use on a resident’s buttocks and for a stage 2 sacral wound, but both had passed their expiration dates. An LPN, the Unit 100 Manager, the DON, and the Administrator all stated expired medications should not be used and might be ineffective.
An opened, undated vial of Tubersol was found in the Hall B medication refrigerator during observation. The facility policy required medications and biologicals to be stored properly per manufacturer guidance, and the manufacturer stated a Tubersol vial in use for 30 days should be discarded. Staff, including an LPN, the IP/SDC, the DON, and the Administrator, stated multidose vials should be dated when opened so staff would know when to discard them.
A resident admitted with acute osteomyelitis, renal abscess, and perinephric abscess had an active order for IV Meropenem when surveyors observed a full IV Meropenem bag hanging in the room with a discard date that had already passed. An LPN reported she had set up the antibiotic before discovering the PICC would not flush, did not notice the expired discard date, and left the bag on the IV pole. Facility policy addressed expiration and beyond-use dates but did not direct staff on handling medications past discard dates, while the DON and Administrator stated that nurses and unit managers were expected to check medication rooms and ensure expired medications were removed.
Thawed COVID-19 vaccine was found in the med refrigerator without a thaw date or BUD on the box. Surveyors noted the box had a serial number, lot number, manufacturer expiration date, and pharmacy label, but no visible thaw date or BUD. An LPN said he did not know the vaccine expired 90 days after thawing, an RN could not recall the requirement, and the IP and DON stated staff had been going by the manufacturer expiration date.
Improper storage of refrigerated medications, vaccines, and insulin was identified when the medication refrigerator was observed at 48 F, with ice buildup in the freezer and repeated temperature logs below the required 36 F to 46 F range. Fifty-eight Afluria vaccines were tightly packed in a drawer without space for air circulation, and a resident’s insulin was used after its opened and expiration dates. Staff interviews showed uncertainty about the proper temperature range and storage requirements.
Surveyors found that controlled drugs, including lorazepam oral concentrate and injectable vials, were stored in unlocked or improperly secured conditions in medication refrigerators. An LPN and unit managers reported that they believed the locked medication room and locked refrigerator provided adequate double-lock security and were unaware that refrigerated narcotics required a separate, affixed lock box. Observations showed narcotic lock boxes in the refrigerators were either absent or not permanently affixed, contrary to facility policy requiring controlled substances to be stored in separately locked, permanently affixed compartments.
Unattended medication carts were left unlocked on multiple occasions. An RN left one cart in a hallway near residents, an LPN left another cart unlocked while administering meds via G-tube, and another RN left a cart unlocked while stepping away to grab a pen. The facility policy required carts to be kept closed and locked when out of the nurse’s sight, and the DON and Administrator stated carts were expected to be locked when unattended.
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