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F0755
D

Expired Vaccines Found in Medication Refrigerators

Spearfish, South Dakota Survey Completed on 08-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that two medication room refrigerators contained expired vaccines, including influenza and pneumococcal 13-valent vaccines. Specifically, ten expired influenza vaccines and one expired pneumococcal vaccine were found in one refrigerator, while three expired influenza vaccines and one expired pneumococcal vaccine were found in another. Staff interviews revealed confusion and lack of clarity regarding responsibility for checking and removing expired vaccines. One RN believed night staff were responsible, while an LPN thought the pharmacist checked for expired medications monthly and was unaware of the expired vaccines' presence. The DON was also unaware of the expired vaccines and stated that the consultant pharmacist was expected to check for expired medications monthly, but all staff administering vaccines should have checked expiration dates. Facility policy required staff to store, administer, and discard pharmaceuticals according to procedures, including sending expired medications for destruction. Despite these policies, expired vaccines remained accessible in the medication refrigerators, available for administration to residents.

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