Failure to Remove Expired Medications and Improper Storage of Lorazepam
Penalty
Summary
The facility failed to ensure proper medication management in several instances. During a review of the medication cart, a 12-count card of ferrous sulfate 325mg tablets with an expiration date of 03/2025 was found in the cart after the expiration date had passed. The nurse responsible for the cart admitted that expired medications should be removed immediately and that it is the nurse's responsibility to check for expired medications before the morning medication pass, but confirmed that this check had not been performed. The expired medication was only removed after it was pointed out during the review. Additionally, three bottles of oral liquid Lorazepam, which require refrigeration according to the manufacturer’s label, were found stored in the narcotic box of a medication cart instead of in the refrigerator. The LPN present was unaware of the storage requirements, and only after consultation with the ADON was it confirmed that the medication should be refrigerated. Furthermore, a bottle of Lorazepam for a resident whose order had been discontinued was still present in the medication cart, contrary to facility policy that requires discontinued medications to be disposed of the same day. The facility’s policy and the medication insert both specify the need for proper storage and prompt removal of expired or discontinued medications.