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F0761
D

Failure to Discard Expired and Undated Multi-Dose Vials of TB PPD

Jefferson City, Tennessee Survey Completed on 06-18-2025

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

Facility staff failed to properly manage multi-dose vials of Tuberculin (TB) purified protein derivative (ppd) in accordance with facility policy and manufacturer guidelines. During an observation of the medication refrigerator in the Unit 2 Medication Storage Room, one multi-dose vial of TB ppd was found to be opened and dated 5/6, but not discarded after 30 days as required by the manufacturer. The year of opening was also not indicated. A second opened multi-dose vial of TB ppd was found without any date indicating when it had been opened. Both vials were available for resident use at the time of the survey. Interviews with the RN and the DON confirmed that the vials had not been managed according to policy, as one was not discarded after the required period and the other lacked an opened date. The facility's policy and the manufacturer's guidelines both require opened multi-dose vials to be dated and discarded within a specified timeframe to ensure potency and safety. The failure to follow these procedures resulted in expired and undated medication being stored and available for use.

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