Expired Medications and Loose Pills Found in Medication Carts and Storage Rooms
Penalty
Summary
Surveyors observed that the facility failed to properly manage medication storage and labeling in multiple medication carts and storage rooms. Specifically, expired medications and loose, unidentified pills were found in three out of five medication carts and two out of three medication storage rooms. Examples included an expired inhaler, expired Vitamin C, expired promethazine suppositories, and expired simethicone tablets, as well as several loose pills of various shapes and colors in the drawers of the medication carts. These findings were confirmed during observations conducted in the presence of medication aides and nurses, all of whom acknowledged that expired medications and loose pills should not be present in the carts or storage rooms. Interviews with staff, including medication aides, nurses, and the DON, revealed that there was an established process for checking for expired medications, with responsibilities assigned to night shift nurses and unit managers. However, the presence of expired medications and loose pills indicated that these checks were not being performed thoroughly. Staff members consistently stated that expired medications and loose pills should not be present, and the DON acknowledged that the process was not being followed as intended.