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F0921
F

Expired Saline Eyewash Solutions at Multiple Facility Locations

Bonham, Texas Survey Completed on 04-24-2025

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 maintain a safe, functional, sanitary, and comfortable environment by not ensuring that saline eyewash solutions at four locations—the kitchen, laundry, east wing medication room, and east wing shower room—were within their expiration dates. Observations revealed that all reviewed eyewash stations contained expired saline solutions, with specific expiration dates noted on the bottles. Staff interviews confirmed that the expired solutions had not been replaced, and there was confusion among staff regarding responsibility for monitoring and replacing the eyewash solutions. The maintenance staff member acknowledged responsibility for checking the eyewash stations but admitted to missing the scheduled checks, and the dietary supervisor indicated that replacements had not been available when needed. Further interviews with staff, including a registered nurse, a certified nursing assistant, the assistant director of nursing, and the administrator, revealed a lack of clarity regarding the monitoring process and policy adherence for eyewash solution expiration. The facility's policy on the storage of drugs and biologicals requires that outdated or deteriorated items be returned or destroyed, but this was not followed for the eyewash solutions. No information about residents' medical history or condition was provided in relation to this deficiency.

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