Expired Medications and Improper Medication Administration Practices Identified
Penalty
Summary
Expired intravenous (IV) fluids and penicillin tablets were found in the third-floor medication room during an observation with the Infection Preventionist and nursing supervisor. The IV fluids had an expiration date of March 2025, and the penicillin tablets expired on April 26, 2025. Staff interviews revealed that the night supervisor was responsible for checking the IV cart for expired medications, and the emergency stock box was typically reviewed by unit nurses or supervisors. However, there was no record of these checks, and the Director of Nursing Services (DNS) could not explain why the expired medications were not discarded, despite a facility policy requiring removal of medications by the expiration date. A resident with dementia, heart failure, and peripheral vascular disease was observed with a medication cup containing two white pills at the bedside. The resident stated that staff usually left the medication for self-administration, and that the last three doses had been taken independently. The resident had not taken the current dose because the pills were not split as needed. Staff interviews revealed uncertainty about who left the medication at the bedside, and the LPN who administered medications that morning denied leaving any pills for the resident. Facility policy requires staff to observe residents swallowing all administered medications and prohibits leaving medications at the bedside.