Failure to Secure Controlled Medications and Timely Discard Expired Drugs
Penalty
Summary
The facility failed to ensure that controlled medications were securely stored and that expired medications were discarded in a timely manner. During an observation of the H Unit medication storage refrigerator, Ativan injection syringes, a controlled medication, were found in a red plastic box designated for controlled substances, but the box lacked a lock or secure device. This was confirmed by both an LPN and the Director of Nursing, who acknowledged that the controlled medication box should have been secured according to facility policy. Additionally, in the A Unit medication storage refrigerator, expired antibiotics, including multi-dose bottles of Cefpodoxime and a bag of Meropenem IV solution, were found past their discard date. An LPN confirmed that these medications were expired and should have been discarded or returned to the pharmacy. The Director of Nursing also confirmed that expired medications should not have remained in storage. These findings were based on direct observations, staff interviews, and a review of facility policies.
Plan Of Correction
Refrigerator on Unit H was secured with a lock on the red narcotic box inside the refrigerator. Pharmacy conducted an audit of all medication refrigerators to ensure all had a double locking system. Unit Licensed Practical Nurse will conduct daily audits to ensure narcotic medications are double locked. Audits will continue for four weeks, then weekly for four weeks, then monthly for four months, then quarterly. All licensed nursing staff will be educated by the Director of Nursing/Designee on the need for double locks of narcotic medications. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25. And medication rooms expired or discontinued medications. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance.