Expired Medical Supplies Not Discarded in Medication Room
Penalty
Summary
The facility failed to discard expired medical supplies in one of two medication rooms, specifically the back medical room. During an audit conducted by the Director of Nursing, five expired items were identified in this room. The Director of Nursing confirmed in an interview that these expired items were found during her audit and acknowledged that they should have been removed by the registered nurse on the third shift. This deficiency was identified through a review of facility audits and staff interviews.
Plan Of Correction
Re-education was initiated on 7/2/2025 with registered nurses and licensed practical nurses, providing on-the-spot education for monitoring expired supplies and ensuring expiration dates are checked on supplies prior to being put into use. Education will be complete by 7/15/2025. A registered nurse meeting was completed on 7/10/2025, which included a review of on-the-spot education regarding the current process to confirm all registered nursing staff understand their role in ensuring compliance. Those not in attendance will receive a one-on-one conversation regarding on-the-spot completion and to ensure they understand their role in ensuring compliance by 7/15/2025. The Director of Nursing will continue with weekly audits of medication and supply rooms on the units to ensure no expired medical supplies are present. The Quality Assurance and Performance Improvement team is scheduled for an additional meeting on 7/11/2025 and will review the current process and the results of the audits related to expired supplies. All expired supplies have been removed from storage, returned to purchasing, and disposed of. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey