Medication was left unattended at the bedside for one resident, and a prescription bottle of Nystatin powder belonging to another resident was found at a different resident’s bedside. An LPN acknowledged leaving oral meds at the bedside despite knowing they should not be left unattended, and the DON confirmed the expectation was to observe the resident swallow the meds. The bedside Nystatin bottle was not from the facility pharmacy and there was no active order for it.
Medication Label Did Not Match EMAR Order: An LPN administered a pharmacy-prepared Benztropine pack labeled 0.5 mg even though the EMAR order listed Benztropine Mesylate 1 mg with directions to give 0.5 mg twice daily. The LPN acknowledged the mismatch, and the DON confirmed the order and label did not correspond for a resident with schizophrenia, major depressive disorder, and moderate cognitive impairment.
Improper labeling of opened multi-dose medication vials was found on two medication carts. An LPN and the ADON identified that several opened multi-dose vials, including insulin and ophthalmic solutions, were missing open dates or had dates that did not align with the facility policy for dating and discarding after opening. Residents affected had active orders for the medications observed, including eye drops and insulin.
An LPN observed that insulin pens on a medication cart for two residents were in use but not dated when opened. Facility policy and in-service materials stated insulin should be dated when opened and discarded after 28 days. The LPN stated undated insulin could not be verified as safe to administer, and the DON stated nursing staff should ensure insulin on medication carts is labeled with an open date.
Unsecured medications and treatment solutions were found accessible in a resident room, including multiple bottles of Dakin's solution, ethyl alcohol, and hydrogen peroxide left on a table, in a pail, and on a counter. Surveyors also observed an unlocked, unattended med cart; an LPN acknowledged leaving it unsecured, and the DON stated carts should remain locked unless actively in use.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
Improper Storage and Dating of Insulin on Medication Cart: An LPN observed several open insulin products on a medication cart that were either undated or beyond the manufacturer’s 28-day room-temperature limit, including Novolog, Humalog, Insulin Aspart, and a Humalog KwikPen for multiple residents. The facility policy required storage per manufacturer specifications, and the LPN stated undated insulin could not be verified as safe to administer; the DON confirmed insulin on carts should be labeled with an open date and kept within the 28-day use period.
Medication labels did not match MAR orders for a resident during med pass. An LPN removed pharmacy-prepared blister packs labeled Gabapentin 300 mg and Propranolol HCl ER 80 mg from the locked narcotic box and administered two tablets/capsules of each because the MAR ordered Gabapentin 600 mg and Propranolol HCl ER 160 mg. The LPN said the discrepancy had been present since admission, and the DON and Administrator said staff had not reported it; the resident was cognitively intact with a BIMS score of 13.
A deficiency was cited when surveyors found that medications on one medication cart were not stored and labeled correctly, including Restasis eye drop vials placed inside an Albuterol nebulizer solution package labeled for a resident. The facility’s storage policy did not address placing one medication inside another’s packaging. A resident with a history of stroke, dysphagia, and severely impaired cognition had a family representative who observed a nurse enter the room to give a nebulizer treatment using a vial that was clearly not the correct medication, and the error was identified before administration.
A wound care cart containing medications such as Nystatin, Santyl, and Dakin's solution was left unlocked and unattended for fifteen minutes, with wound cleanser unsecured on top. An RN later returned to secure the cart. Both the RN and DON confirmed that the cart should have been locked at all times when not in use, in accordance with facility policy.
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