Expired Medications and Delayed E-Kit Replacement Identified
Penalty
Summary
The facility failed to ensure that all medications stored in its drug storage areas were available for use and had not expired, as well as to replace pharmaceutical emergency kits (E-Kits) within the required timeframe after opening. During observations and interviews, multiple expired medications were found in storage cabinets, countertop baskets, and medication carts, including normal saline unit doses, phosphorus supplements, valproic acid, lactulose, sucralfate, mineral oil, bisacodyl, ondansetron, and hyoscyamine. The Infection Preventionist confirmed that these medications should have been disposed of according to the facility's policy and procedure, which requires immediate removal of outdated, contaminated, or deteriorated medications. Additionally, the facility did not replace E-Kits within 72 hours of being opened, as required by its policy. Observations revealed that at least two E-Kits had been opened and not replaced within the specified timeframe, with billing slips and staff interviews confirming the delay. The Infection Preventionist acknowledged that the replacement of the E-Kits was not completed within the policy's required 72-hour window.