Failure to Follow Pharmaceutical Procedures and Remove Expired Supplies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for residents. Specifically, a nurse administered omeprazole delayed release 20 mg to a resident with a gastrostomy tube by opening the capsule and mixing it with water, despite the medication label clearly stating, "Do not crush or do not open! Should swallow whole." The nurse admitted to not reading the label and acknowledged that the medication should not have been opened, and that the physician should have been contacted to request a liquid form suitable for tube administration. The resident involved was a female with multiple complex diagnoses, including multiple sclerosis, dementia, chronic obstructive pulmonary disease, dysphagia, and GERD, and was dependent on a feeding tube for nutrition and medication administration. Additionally, the facility failed to ensure that expired medical supplies were removed from medication rooms. During observations, one box of suction catheter kit expired on 06/07/2025 was found in the A-wing medication room, and one box of suction catheter tray expired on 07/28/2024 was found in the C-wing medication room. The regional RN acknowledged the presence of these expired items and stated that nurses should have discarded them according to facility policy. Although there were no residents currently requiring suction, the expired supplies remained accessible in the medication rooms. Facility policy required staff to observe manufacturer medication administration guidelines and to discard expired medications and supplies. However, these procedures were not followed, as evidenced by the improper administration of omeprazole and the failure to remove expired suction supplies from medication rooms.