Expired Controlled Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored in accordance with professional standards, as evidenced by the presence of an expired controlled medication, Morphine Sulfate 20mg/5ml oral suspension, in the Hall 300 Nurse's medication cart. The medication, prescribed for a female resident with chronic obstructive pulmonary disease and severe cognitive impairment, had an expiration date of 12/28/2024 but was still found in the locked controlled medication storage during an observation. The nurse present at the time, who had been working at the facility for three weeks, acknowledged the medication was expired but was unaware of whose responsibility it was to remove expired medications from the cart. The Director of Nursing confirmed that the expired medication should not have been stored in the medication cart and stated that it was the responsibility of the nurse using the cart to remove expired medications. Review of the nurse's competency checklist indicated she had been assessed as competent in areas including checking medication expiration dates. The facility's policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued or outdated medications.