Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
Surveyors identified that expired medications and supplies were not properly disposed of in two of three medication storage rooms. On the 4th floor, expired hemoccult cards and developer were found in a cabinet drawer, along with unopened tubes of Collagen Hydrogel and an indwelling catheter, some of which were expired. On the 3rd floor, an unopened box of Lorazepam, a Schedule IV controlled medication, was stored in a medication refrigerator without being secured in a locked, affixed box as required. The lock box present in the refrigerator was marked 'DO NOT USE,' and staff were unaware of the reason or unable to access it. The Director of Nursing Services (DNS) was not aware that the lock box was not being used for controlled medications or that it was marked as unusable. A review of the maintenance log did not show any entry regarding the lock box being broken. Additionally, expired COVID-19 test kits and a partially used gallon of distilled vinegar with a past use-by date were found in the 3rd floor medication room. The pharmacy consultant confirmed that non-medication items would not typically be reviewed during monthly inspections and could not confirm if the Lorazepam was present during the last inspection, as it was not noted in the summary report. Facility policy requires Schedule II-V medications to be kept in a separately locked, permanently affixed compartment, with a different access system from non-scheduled medications, which was not followed in this instance.