Expired Nutritional Supplement Administered Due to Labeling and Storage Oversight
Penalty
Summary
A Licensed Practical Nurse (LPN) administered Med-Pass 2.0, a nutritional supplement, to a resident from a multi-dose carton that had been opened and stored beyond the manufacturer's recommended timeframe for safe consumption. The carton was labeled with an open date, and the manufacturer's instructions specified that the product should be consumed within four days if refrigerated. The LPN was observed pouring the supplement for the resident and later stated she was unsure of the correct discard timeframe, mistakenly believing it to be 30 days after opening. She acknowledged that the product should have been disposed of earlier and that administering expired Med-Pass could cause gastrointestinal issues. The facility's medication storage policy did not include instructions for labeling or discarding nutritional supplements. The resident who received the expired supplement had a history of intellectual disabilities, atrial fibrillation, and postural kyphosis, and was unable to participate in a mental status assessment due to poor cognitive status. The Director of Nursing confirmed that staff are expected to follow both facility policy and manufacturer recommendations for storage and disposal of such products.