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F0755
D

Expired Medications Not Removed from Medication Room

Conroe, Texas Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide proper pharmaceutical services by not ensuring that expired oral Vancomycin solutions were removed from the Station 1 Medication Room refrigerator. During an inventory check, an open and in-use bottle of Vancomycin Oral Solution labeled 'Do Not Use After' a past date was found for one resident, and a sealed bottle with the same expiration date was found for another resident. Both residents were no longer in the facility, yet their medications remained in the medication room after their discharge. The LVN present confirmed that the medications were expired and should have been removed immediately after the residents' discharge. Interviews with the LVN and the DON revealed that nurses were expected to inspect medication rooms daily for expired medications and to remove all medications belonging to discharged residents. Facility policy required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that all expired medications be removed from active supply and destroyed. Despite these policies, expired medications remained accessible in the medication room, indicating a failure to follow established procedures for medication storage and removal.

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