Failure to Discard and Account for Medications After Resident Expiration
Penalty
Summary
The facility failed to properly store and discard medications belonging to a resident who had expired. During an observation in the medication room, a locked black box labeled with the resident's name was found on the top shelf of a storage cabinet. The registered nurse present was unaware of the box's existence, did not know the code to open it, and could not identify the medications inside. There was no record of the drug contents in the box, and it was unclear whether any controlled substances were present. The director of nursing confirmed that the facility did not have a specific policy for handling medications of residents who had expired and acknowledged that the medications should have been discarded to prevent diversion or misuse. The facility's policy stated that discontinued, outdated, or deteriorated medications should be returned or destroyed per pharmacy instructions, but this was not followed in this case. The resident involved had a history of sepsis, type 2 diabetes mellitus, end stage renal disease, and anemia, and had expired prior to the discovery of the medications.