| 55 |
HANDMAKER HOME FOR THE AGING |
35016 |
2221 NORTH ROSEMONT BOULEVARD |
TUCSON |
AZ |
85712 |
2016-10-06 |
431 |
E |
0 |
1 |
VEV011 |
Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that medications were properly stored, and that expired medication and laboratory supplies were not expired and available for resident use. The facility also failed to ensure that the medication refrigerator temperatures were consistently monitored. Findings include: A medication storage observation was conducted on (MONTH) 3, (YEAR), on all of the nursing units and the following concerns were identified: Kalmanovitz secured dementia unit: In the Medication storage room, there was an unlocked medication refrigerator which contained a locked plastic narcotic box. However, the narcotic box was not affixed to the inside of the medication refrigerator. Further observations revealed that the plastic narcotic box did not fully close, and the opening was large enough to withdraw medications from the box, without unlocking it. Inside the plastic narcotic box were a total of 23 vials of Lorazepam (an anti-anxiety medication). At this time, the medication refrigerator temperature log for (MONTH) (YEAR) was reviewed and revealed that there was no documentation that the temperature of the refrigerator was monitored on one day. An interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that she had contacted the maintaince department and had the narcotic box permanently secured. At this time, another observation of the narcotic box was conducted. Inside of the unlocked refrigerator was a locked plastic narcotic box. The narcotic box was now attached to a shelf in the refrigerator. However, the shelf was able to be easily removed, along with the narcotic box. Rich unit: In the medication storage room there were eight yellow cap laboratory tubes, which had an expiration date of (MONTH) (YEAR). In addition, the medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were four days with no evidence that the temperature had been monitored; in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored; and in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored. Following this observation, an interview was conducted with a LPN (Licensed Practical Nurse/staff #6). She stated that the laboratory test tubes were occasionally used when blood was needed to be drawn. Staff #6 stated that the night shift nurses were responsible to monitor and document the medication refrigerator temperatures. She stated that the day shift nurses will now need to double check that it was done. Bregman unit: On the Medication cart, there was one vial of Lantus Insulin with an opened date of (MONTH) 26, (YEAR). Per the manufacturer's instructions, the insulin would expire 28 days after the date of opening. There were also two opened sets of Insulin Control Solution, which had an expiration date of (MONTH) (YEAR). In addition, there was an unlocked medication refrigerator which was located inside the locked medication storage room. Inside of the refrigerator was a locked narcotic box, however, it was not permanently affixed to the refrigerator. The narcotic box contained a box of 15 tablets of Dronabinol (a controlled drug used to treat nausea and vomiting associated with chemotherapy). The medication refrigerator temperature logs were also reviewed and revealed the following: in (MONTH) (YEAR), there was one day without a recorded temperature; in (MONTH) (YEAR), there were six days without a recorded temperature and in (MONTH) (YEAR), there were four days without a recorded temperature. Following this observation an interview was conducted with a LPN (staff #106), who stated that it was the night shifts responsibility to check weekly for expired medications and supplies. Golding unit: The medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were eight days without a recorded temperature; in (MONTH) (YEAR), there were two days without a recorded temperature and in (MONTH) (YEAR), there were two days without a recorded temperature. An interview was conducted on (MONTH) 4, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she was not aware that the refrigerated narcotic boxes were not permanently affixed. She stated that the boxes need to be secured and that locking them to a removal shelf did not ensure that they were permanently affixed. The DON also stated that both the laboratory provider and the nursing staff were responsible to ensure that expired items were not available. According to the DON, the night shift licensed staff were responsible to check the medication refrigerator temperatures nightly, and the medication carts for expired medications and medical supplies. Per the DON, any expired medication or medical item, should be discarded and replaced. A facility policy titled, Storage of Medications included The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also included the following: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Another facility policy titled, Controlled Substances included The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. The policy also included the following: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The container must remain locked at all times, except when it is accessed to obtain medications for residents. |
2020-09-01 |