Expired Medications, Missed Doses, and Medication Management Failures
Penalty
Summary
The facility failed to adhere to its pharmaceutical services policies in several key areas. Surveyors observed that expired medications and products, including a nutritional shake, sodium chloride, acetic acid, estradiol cream, and an inhaler, were available for resident use. Nursing staff acknowledged the presence of these expired or improperly stored items and confirmed that they should have been discarded according to facility policy. Additionally, a nurse administered more eye drops than ordered by the physician to a resident, contrary to the documented medical order and facility procedures for medication administration. The facility did not maintain a consistent medication re-ordering process, as evidenced by multiple entries in the re-ordered medication binder showing that numerous residents were either out of medications or had only a few doses left. Nursing staff stated that medications were supposed to be ordered five days in advance, but this was not consistently done. Furthermore, the facility did not ensure timely and consistent availability of resident medications. Several residents did not receive their prescribed medications due to delays in pharmacy delivery or missing cycle medications, and staff interviews confirmed that this was a recurring issue. The facility's agreement with the pharmacy for monthly cycle medication refills was not being fulfilled as planned. Surveyors also found discrepancies in the contents of the intravenous emergency kit, where two bags of sodium chloride were present but not listed on the kit's label. Nursing staff acknowledged that the kit contents did not match the label and stated that the pharmacy was responsible for ensuring accuracy. These failures collectively had the potential to negatively impact resident care and safety, as the facility did not follow its own policies for medication storage, administration, re-ordering, and emergency kit management.