Expired and Improperly Labeled Medications Found in Facility
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by the presence of expired and improperly labeled medications in their medication carts. During an observation of the Arcadia unit medication cart, an unopened box of OHC COVID tests with an expiration date of December 30, 2023, was found. Employee 2, an LPN, confirmed the tests were expired and indicated they would be discarded. Additionally, on the 3rd floor short hall medication cart, two insulin degludec pens, one insulin aspart pen, and a bottle of Medline Liquid Active Protein supplement were found without open dates indicated. Employee 3, a Graduate Practical Nurse, confirmed these items were not dated when opened. The facility's policy on the storage of medications requires that insulin vials and pens be dated when first used and that outdated medications be immediately removed from stock and disposed of according to procedures. The Director of Nursing (DON) confirmed during interviews that the COVID tests should have been discarded and that the insulin pens should have been dated when opened. The DON also confirmed that the liquid protein should have been dated when opened, acknowledging that medications with a shortened shelf life after opening should be dated. These findings indicate a failure to comply with the facility's medication management policies, as well as state regulations regarding pharmacy services.
Plan Of Correction
Expired COVID test kit from Arcadia was discarded. Insulin Degludec pen, Insulin Aspart pen, and Medline Liquid Active Protein on Third Floor were discarded. A Comprehensive review of medication carts will be conducted to ensure that all Insulin Pens and Medline Liquid Active Protein are dated when opened and that there are no expired COVID test kits. The facility will take further steps to ensure that the problem does not re-occur by in-servicing all licensed nursing staff on F Tag F761 with a focus on Insulin Pens and Medline Liquid Active Protein as well as expired medications. Compliance will be monitored by the Director of Nursing / Designee using the Label/Storage of Drugs Audit through 5 random audits weekly x 3 weeks then monthly x 2 months to ensure that there are no expired COVID kits and Insulin Pens/Medline Liquid Active Protein has an open date, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.