Expired Medications and Improper Storage in LTC Facility
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with professional standards for expiration dates and storage. During a recertification survey, it was observed that one of the medication rooms contained an open box of expired [MEDICATION NAME] 1.5 Cal, which was being used for a resident's feeding. Additionally, expired nicotine patches were found in a medication cart without proper labeling. Interviews with nursing staff revealed that the expired items should not have been in use, and it was the responsibility of the medication nurses to check and dispose of expired items. Furthermore, a resident was found with multiple medications left unattended on their bedside table, despite not having documented permission to self-administer medications. The medications included Carvedilol, an anti-depressant, Aspirin, Apixaban, Folic Acid, Levetiracetam, a stool softener, and an anti-acid. A nurse had left the medications with instructions for the resident to wait for water, which was against facility policy. The nurse acknowledged that the medications should have been secured in the medication cart while retrieving water.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The expired [MEDICATION NAME] feed and nicotine patches were immediately discarded. Resident #60 received appropriate medications on [DATE] and resident has been discharged from the facility. Resident’s preference was to have all medications administered by the nursing department and not to self-administer medications. Resident #90 was assessed and had no negative outcome related to tube feed. MD made aware. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs, and a medical record review was completed with no abnormal findings. All nursing staff who administered the expired [MEDICATION NAME] and did not discard the expired nicotine patches were re-educated on checking of expiration dates and discarding as appropriate. Nurse manager #6 was re-educated on med pass policy to not leave residents' medications at the bedside and to assure medications are consumed. She has since been re-audited and successfully redemonstrated her understanding. All residents receiving tube feed and medication have the potential to be affected by practice. DNS and Maintenance Director completed a full house audit of tube feeding expiration dates. Additionally, all medication rooms and medication carts were checked to verify that no medications were expired. Any additional medications/feeds that were found to be expired were immediately discarded. All residents who self-administer medications were audited to verify that a Self Administration evaluation was completed and appropriate. Residents that do not have a care plan for self-administering medications will have medications provided by nurses. The nurses will not leave medications unattended. All Nurses and the Maintenance Director were educated by DON/designee to check expiration dates on all tube feed and medications administered items used. Prior to use, dates will be checked. All Nurses will be re-educated by DON/designee pertaining to proper medication administration. All licensed nurses will be re-educated on the facility procedure for residents that request to self-administer medication. Nursing and Maintenance will monitor expiration of tube feeding and supplies. Weekly audits by Unit Manager/designee of tube feeding will be conducted. Medication cart checks will continue to be checked by Pharmacy Consultant monthly. Tube feed will be checked by maintenance before being brought to the unit to ensure that tube feeding has not exceeded expiration date. Tube feeding will be checked by the nurse prior to hanging it. Audits will be ongoing. Weekly audits on med passes by Unit Managers will ensure medication is not left at the bedside. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is [DATE].