Expired and Unlabeled Medications Found on Medication Carts and in Medication Room
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals within the facility. During observations, two medication carts and one medication room were found to contain expired medications and supplies, as well as an unlabeled, opened bottle of saline nasal spray. Specifically, the Hall #3 medication cart contained an open, unlabeled bottle of saline nasal spray and expired medications, including Morphine 30 mg tablets prescribed for a resident with chronic pain syndrome and Pravastatin 20 mg tablets prescribed for another resident with hyperlipidemia. The Hall #5 medication cart contained an open tube of Hydrocortisone Cream that was expired. Additionally, the medication room contained a large bin of single-use Tuberculin Safety Syringes that were past their expiration date. Interviews with staff revealed that the ADONs and DON were responsible for routinely checking medication carts and rooms for expired medications and supplies, typically every week or two. However, floor nurses were also expected to check their carts for expired items. Staff members acknowledged that expired medications could be ineffective or potentially harmful, and that expired narcotics were to be reported to the DON for removal. Despite these procedures, expired medications and supplies remained on the carts and in the medication room, indicating lapses in the established checking routines. A review of the facility's medication policies confirmed that all drugs and biologicals are to be labeled according to federal and state regulations, and that expired, unused, or unwanted medications should be removed from storage and secured until destroyed. The policies also specified that drugs dispensed for individual residents are not to be used beyond their expiration date. The facility failed to adhere to these policies, resulting in the presence of expired and improperly labeled medications and supplies accessible in resident care areas.