Failure to Ensure Safe Medication Administration and Removal of Expired Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple deficiencies in medication administration and storage. One resident was observed with a cup containing nine unidentified pills left at the bedside without staff supervision, and the responsible nurse admitted to leaving the room to retrieve batteries, leaving the medication unattended. The resident did not have a self-administration evaluation or care plan in place, and the facility's policy required staff to ensure residents took their medication completely before leaving their side. Additionally, expired medications and supplies were found on two medication carts and in the medication storage room. Items such as insulin pens, suppositories, lubricating jelly, melatonin, dressing change trays, glucose control solution, intravenous solution, inhalation solution, hypodermic needles, zinc, and peri-stoma wipes were all found to be expired. Some medications were also labeled for individuals who were no longer residents at the time of the survey. Staff interviews confirmed that nurses, the ADON, the DON, and the pharmacist were all responsible for checking for expired medications and supplies, but these checks were not effectively carried out. The residents involved had significant medical histories, including diabetes mellitus type II, cerebral infarction, hypertension, atrial fibrillation, pain, dysphagia, apraxia, chronic kidney disease, dysarthria, vascular dementia, hyperlipidemia, anxiety, transient ischemic attack, and hypertensive heart failure. Care plans and medication orders were in place for these residents, but the facility failed to ensure medications were administered and stored according to policy, including removing expired items and supervising medication administration.