Expired Medications Found in Facility Medication Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in accordance with professional standards of practice, as evidenced by the presence of expired Heparin lock flush syringes and intravenous fluids in the medication rooms of two units. During the recertification survey, it was observed that eighteen expired Heparin lock flush syringes were stored in the medication rooms on the 2 [NAME] and 2 East Units. Additionally, a bag of expired intravenous dextrose was found. The facility's policy requires that expired medications be removed and disposed of immediately, but this was not adhered to. Interviews with staff revealed a lack of consistent monitoring and removal of expired medications. Licensed Practical Nurse #4 and Registered Nurse #2 acknowledged the presence of expired items and admitted that the medication room is stocked weekly, but expired items were not always identified and removed. Housekeeping staff found expired items but left them for nursing staff to sort, indicating a breakdown in communication and responsibility. The Consultant Pharmacist confirmed that monthly inspections are conducted, and reports are emailed to the facility, yet expired items remained in the medication rooms. The Assistant Director of Nursing/Infection Preventionist stated that daily rounds are conducted, but they had not specifically checked the Heparin flushes. The Unit Manager and other nursing staff admitted to not regularly checking for expired medications, with some not having checked since April 2024. This lack of regular and thorough inspection contributed to the oversight, resulting in expired medications being available in the facility, which is against the facility's protocol and poses a risk to resident safety.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F 761 Immediate corrective Action: The expired [MEDICATION NAME] was removed from the medication room on 2 West and 2 East and discarded immediately on [DATE]. The RNs and the medication nurses on duty were in-serviced on medication storage on [DATE]. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date, and none were found. Element 3 Systemic changes: The facility policy titled Medication Storage was reviewed, and no revisions were needed. All nurses are being in-serviced on Medication Storage policy and procedure. A new process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). An audit tool was developed to monitor for compliance. Element 4 Monitoring of Corrective Changes: On a weekly basis for one quarter, DNS or designee will inspect 2 medication rooms and 2 medication carts, to ensure compliance with medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designee will report findings to Administrator. On a monthly basis, DNS or designee will report findings to QAPI Committee. QAPI Committee to determine if further action is required. Element 5 Monitoring of Corrective Action: Completion Date: (MONTH) 19, 2025 Director of Nursing ADNS/ Designee.