Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, specifically regarding expiration dates, as observed on one of four medication carts reviewed. During an observation, a resident's Artificial Tears (Natural Tears) with an expiration date of 08/2024 was found on the medication cart. The resident involved had multiple diagnoses, including chronic kidney disease, hypertensive heart failure, anxiety disorder, and dry eye syndrome, and was prescribed the Artificial Tears for dry eye syndrome. Interviews with staff, including an RN, the DON, and the Administrator, revealed that the expired medication had been missed during routine checks. The charge nurse was responsible for checking the medication cart each shift, and the pharmacist was responsible for monthly checks. The facility's policy required that all medications, including over-the-counter drugs, be labeled with expiration dates. Despite these procedures, the expired medication remained on the cart, indicating a lapse in adherence to established protocols.