Expired Medications Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove expired medications from two of four medication carts reviewed, specifically the "Colonial 1" and "Heritage" carts. During observations, one bottle with an expired date was found on the Colonial 1 cart, and a bottle of gel 0.5 mg/mL for a resident was found on the Heritage cart with packaging that specified it should not be used after a certain date. Photographic evidence was obtained for both findings. The facility's policy requires that the expiration or beyond-use date on medication labels be checked prior to administration. In an interview, the DON acknowledged that expired medications should not be present in the medication carts and stated that medication carts are checked on Sundays, but indicated there was a need to improve follow-through with these checks.
Plan Of Correction
F755-Pharmacy Services/Procedures/Pharmacist/Records (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On the expired and gel were removed from the medication carts. Audit was conducted of remaining medication carts with no other concerns were noted related to the alleged deficient practice. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; An audit was completed by the Director of Nursing/designee on all medication carts and medication rooms to ensure there were no outdated or expired medications. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By current licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee. Newly hired licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee will conduct audits of medication carts and medication weekly for 4 weeks, then once a week for 4 weeks, and then monthly for 1 month to ensure that there are no expired or outdated medications present and medications are stored properly. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.