Expired Medications Not Disposed of in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not disposing of expired medications in one of its medication rooms (Bluebonnet). During a review and observation, expired medications were found for three residents, including albuterol and ipratropium/albuterol nebulizer treatments that had expired as early as October 2024 and as recently as February 2025. These medications were still present in the medication room despite being expired and, in some cases, despite the residents no longer having active orders for them or having been discharged from the facility. Record reviews indicated that two residents with significant respiratory and neurological conditions, such as cerebral infarction, hemiplegia, COPD, and pneumonia, had expired albuterol medications stored in the medication room. For one resident, there was no active physician order for the expired medication found. Another resident, who had been discharged, still had multiple boxes of expired ipratropium/albuterol in the medication room, with one box expired for several months. The facility's policy required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not followed. Interviews with nursing staff, including an LVN, ADON, and DON, revealed that responsibility for checking for expired medications was shared among nurses, medication aides, and nurse managers, with expectations for daily and weekly checks. However, the presence of expired medications indicated that these checks were not consistently performed. Staff acknowledged that expired medications should have been discarded and that the oversight was not identified until brought to their attention during the survey.