Failure to Maintain Medication Cart Integrity and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to provide adequate pharmaceutical services, specifically in the management of medication carts and the storage of medications. During observations, a total of 29 loose pills were found across three medication carts, and three expired medications were identified. Staff interviews revealed that medication aides were unaware of the presence of loose pills and expired medications in their carts, despite being trained and required to check for such issues daily or weekly. The medication storage policy reviewed did not address the storage of non-refrigerated medications, and no records of recent cart audits or in-services on medication administration were available. One resident involved had multiple diagnoses, including dementia, diabetes mellitus, and a history of falls, and was prescribed nystatin powder for a fungal infection. Expired bottles of this medication were found in the medication cart assigned to this resident. The resident's care plan included monitoring for skin breaks and infection, but the presence of expired medication in the cart indicated a lapse in following these interventions as ordered. Interviews with the ADON, DON, and administrator confirmed that staff were expected to check medication carts for loose and expired medications at least daily and at every shift. However, the lack of documentation for cart audits and in-services, as well as the presence of loose and expired medications, demonstrated that these procedures were not consistently followed. Staff also indicated that they believed there was little risk to residents due to the availability of backup medications, but this does not address the failure to maintain proper pharmaceutical services as required.