Medication Disposal Non-Compliance
Penalty
Summary
The facility failed to ensure that medications were discarded in a timely manner, as observed in the 1st floor medication room. The facility's policy on Medication Labeling and Storage, dated 11/02/24, requires that multi-dose vials that have been opened or accessed be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. The manufacturer's instructions for Tubersol PPD, a solution used for tuberculosis testing, specify that vials in use for 30 days should be discarded. During an observation on 12/18/24, a vial of Tubersol PPD with an open date of 11/15/2024 was found in the medication storage room refrigerator, indicating it was past the 30-day discard date. An LPN confirmed that the vial was past its discard date and should have been discarded.
Plan Of Correction
1. Expired TB solution was discarded in the appropriate container on 12-18-24. 2. Facility checked all medication refrigerators on 12-18-24 for any other expired meds and none were found. 3. Education will be provided to the licensed nursing staff regarding monitoring open medication for expiration dates. 4. Audits will be completed by Director of Nursing or designee weekly x 4 weeks of all medication refrigerators for expired medications. Refrigerators will then be checked monthly by RN supervisors for expired meds. 5. Process will be monitored in Quality Assurance and Improvement meeting to ensure this process is sustained.