Failure to Label and Remove Expired or Undated Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired or undated medications on two out of three medication carts reviewed. Specifically, Latanoprost ophthalmic solution, used to treat glaucoma, was not labeled with an expiration date for three residents, and an expired bottle was not removed from the cart for another resident. Additionally, a Humalog KwikPen (insulin lispro) was found on a medication cart without an open date, despite manufacturer instructions requiring it to be discarded 28 days after removal from refrigeration. Observations revealed that multiple bottles of Latanoprost for several residents lacked open dates, and one bottle remained on the cart past its recommended use-by date. The Humalog KwikPen for a resident with diabetes was also undated after being placed on the medication cart, contrary to storage guidelines. These findings were corroborated by record reviews, which confirmed the medication orders and the absence of required labeling. Interviews with facility staff, including the ADON, DON, and the facility pharmacist, indicated that responsibility for medication cart oversight was shared among staff and managers, with periodic audits conducted. The facility's own policy required immediate removal of outdated medications and proper labeling with open and expiration dates, but these procedures were not consistently followed, resulting in the identified deficiencies.