Expired Over-the-Counter Medications Found in Main Medication Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals in the main medication storage room were labeled and stored in accordance with professional standards, specifically by allowing 11 unopened over-the-counter medication bottles to remain in stock past their expiration dates. During an observation, an LVN identified these expired medications, which included antacids, laxatives, supplements, and vitamins, all with expiration dates ranging from several months prior to the survey. The LVN explained that the process for organizing medications involved placing older stock in front, but acknowledged that expired items may have been overlooked or accessed out of order. Interviews with facility staff revealed that the Medical Records Clerk was responsible for ordering, stocking, and removing expired medications, with the Pharmacy Consultant serving as a backup. The DON confirmed this arrangement and stated that the expired medications were likely missed during routine checks. The Medical Records Clerk reported conducting monthly checks for expired medications, with the last check occurring the previous month, and noted that nurses were also expected to help identify and remove expired stock. The Pharmacy Consultant indicated that her inspections of the medication rooms were periodic and not comprehensive, with her most recent check of the medication carts occurring the previous month. The Executive Summary of the Consultant Pharmacist's Medication Regimen Review documented a medication cart audit but did not indicate a review of the medication supply room. Staff interviews consistently acknowledged the risk that expired medications could be administered to residents, potentially resulting in reduced effectiveness.