| 93 |
RIO RANCHO CENTER |
325033 |
4210 SABANA GRANDE SE |
RIO RANCHO |
NM |
87124 |
2017-02-14 |
431 |
E |
0 |
1 |
R9L211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. That access to non-controlled discontinued drugs that were stored in open containers in the two medication rooms, without being double-locked, were not readily and easily available for staff members' personal use 2. that insulin vials were labeled when opened and that insulin vials were not being used greater than 28 days from date they were opened. These deficient practices have the potential to negatively impact all 112 residents, identified on the alphabetical list provided by the Administrator on [DATE], through semi-restricted access to discontinued medications by staff and for residents to receive medications that have lost their potency and effectiveness. The findings are: [NAME] On [DATE] at 12:15 pm, the medication storage observation of the North and South Hall medication rooms revealed opened boxes indicated for discontinued medications all easily accessible to staff members' personal use. The opened boxes contained the following medications: [REDACTED] 1. latanoprost (used to reduce intraocular pressure in the eye) 2. Spiriva (an inhaler used to help expand lung passages) 3. Nicotine Transdermal patches 21 mg (6) (used to reduce the urge to smoke) 4. albuterol nebs (used to help expand lung passages) 5. Alphagan (used to reduce intraocular pressure in the eye) 6. Flovent (a steroid inhaler that expands lung passages) B. On [DATE] at 1:40 pm, during interview, the Unit Manager for the North hall stated that the discontinued medications or medications of discharged residents are stored in the opened box. During the night shift, the nurse catalogs the medications, the medications are then placed in a box that is sealed and ready for the pharmacist or pharmacy courier (a messenger who transports goods or documents) to pick up from the facility once a week. C. Record review of the facility's policy titled Delivery and Receipt of Medication and Pharmacy Documents from the Facility to the Pharmacy, last revised on [DATE], revealed the following: .Facility should securely store the medications that Facility intends to return or sent to Pharmacy for repackaging until the medications are picked up by Pharmacy courier . D. On [DATE] at 11:26 am, during observation of the medication cart, revealed one (1) opened undated multi-dose vial of insulin indicated for resident use, no date was indicated on the vial. E. On [DATE] at 11:35 am, observation of the medication cart, revealed two (2) opened and dated multi-dose vials of insulin indicated for resident use, that had been opened beyond the 28 days that manufacturer's recommend. Also found during this observation was one (1) Lantus (a long-acting insulin) Insulin pen with no resident identification or when it was opened any where on the insulin pen. F. On [DATE] at 11:37 am, during interview, Licensed Practical Nurse (LPN) #1 stated, that all insulins are expired after being opened for 28 days, including insulin flex pens. [NAME] On [DATE] at 1:38 pm, during interview, the Unit Manager for the North hall confirmed that the one opened undated injectable vial of insulin should have been dated and that the two opened dated injectable vials of insulin were beyond the 28 days that are recommended by the manufacturer. H. Record review of the facility's policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, last revised on [DATE] revealed the following: .safety and security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines .Once any drug or biological package is opened, follow manufacturer/supplier guidelines for in use expiration dating. Drugs and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are destroyed by the Center . |
2020-09-01 |