Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that Resident #49 received treatment and care in accordance with professional standards of practice. Specifically, the resident was administered 14 doses of expired levetiracetam, a seizure medication, from January 10, 2025, to January 17, 2025. The facility's policy on medication administration required that the individual administering the medication verify the expiration date had not been exceeded. However, the medication card for levetiracetam had an expiration date of December 30, 2024, and was not checked by the nurses before administration. Licensed Practical Nurse #31 admitted to administering the expired medication without realizing it was expired, and there was no documentation that the attending physician was notified of the error. Resident #49 had a history of convulsions, dementia, and heart failure, with a documented severe cognitive impairment and seizure disorder. Despite the administration of expired medication, nursing progress notes from January 10 to January 16, 2025, did not document any seizure activity for the resident. Interviews with nursing staff and the Director of Nursing revealed a lack of consistent checking of medication expiration dates and a failure to notify the physician when expired medication was administered. The Director of Nursing acknowledged that nurses were not regularly checking expiration dates and that expired medications should not have been administered due to potential changes in efficacy.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident identified as #49’s [MEDICATION NAME] level will be checked. The expired medication was removed and the MD was notified. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The medication carts were all audited for expired medications and no further expired medications were found. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All licensed nurses will receive education on the medication administration policy. An updated 11p-7a nursing checklist will include removal of all expired medications from the medication cart nightly. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Medication carts will be audited weekly for three months, monthly for three months, and quarterly for six months. Audits will be reported to QAPI monthly. The date for correction and the title of the person responsible for correction of each deficiency: Director of Quality Management.