Expired Emergency Medication Kit Found in Storage
Penalty
Summary
Surveyors observed that an expired emergency medication kit was stored in the facility's medication storage closet. During a concurrent observation and interview, the Director of Nursing confirmed that the emergency kit had an expiration date that had already passed and acknowledged that it should have been replaced. The facility's policy and procedure on medication storage, dated March 2024, requires that outdated, contaminated, or deteriorated medications be immediately removed from stock, disposed of according to proper procedures, and reordered from the pharmacy. The presence of the expired emergency medication kit in the storage area was not in accordance with the facility's own policies and procedures. The Director of Nursing confirmed that having expired medications on hand was not within facility policy. No information was provided in the report regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
F 761 Label/Store Drugs and Biologicals 1. The Medication E-Kit was removed from service immediately, Pharmacy was notified and new Medication E-Kit was replaced the same afternoon by Director of Nursing 6/3/2025. 2. The Director of Nursing completed an audit of all the medication E-Kits in the facility ensuring that all were within compliance. 3. Facility will be conducting weekly rounds by the Director of Nursing and/or designee to assure deficient practice doesn't occur again verifying the dates on the Medication E-Kits in the facility. 4. Findings will be brought to the Quality Assurance Committee by the Director of Nursing and/or designee on a quarterly basis for recommendations. 5. The corrective action will be completed by June 13th.