§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
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Observations:
Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a manner that prevented unauthorized access on one of two nursing units. (Second floor)
Findings include:
Review of the facility policy entitled, "Storage and Expiration Dating of Medications and Biologicals," last reviewed August 1, 2024, revealed that medications and biologicals, including treatment items, were to be securely stored in a locked cabinet/cart or locked medication room that is unaccessible by residents and visitors.
Observation on June 2, 2025, at 10:20 a.m., on the second floor nursing unit, revealed that the treatment cart in the hallway was unlocked and unattended and contained several tubes of medicated creams for pain, bottles of saline solution for nose and eyes, and boxes of alcohol pads that were accessible.
In an interview on June 2, 2025, at 10:30 a.m., the RN Supervisor confirmed that the treatment cart should have been locked.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 06/23/2025
1.Facility is unable to retroactively correct.
2.To identify like residents that have the potential to be affected by this all treatment carts were audited to ensure that they were appropriately locked and unreachable by residents and visitors.
3.To prevent this from reoccurring the DON/designee will educate licensed staff on appropriately locking treatment carts and locating them in an area that is unreachable by residents and visitors.
4.To monitor and maintain ongoing compliance the unit manager/designee will audit treatment carts 3 X a week times 4 weeks and then monthly times 2 to ensure that treatment carts are appropriately locked and not reachable by residents and visitors.
Results of audits to be forwarded to QAPI for review and possible recommendations.
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