Failure to Monitor and Prevent Use of Expired Medications
Penalty
Summary
The facility failed to establish an effective system for monitoring expired medications, resulting in the administration of expired medication to a resident. During an observation in the medication room, a registered nurse was found to have a box of bisacodyl suppositories with an expiration date that had already passed, and only a portion of the original supply remained. The nurse confirmed that the resident had not used the suppositories in a long time, yet medication administration records showed that the resident received the expired suppositories on two occasions after the expiration date. Additionally, a plastic cup containing what appeared to be chocolate Ensure was found in the medication room refrigerator without a cover, label, date, or resident name. The resident involved had a history of atrial fibrillation, heart failure, hypertension, peripheral vascular disease, and constipation, and required set-up assistance for care but was able to walk independently. The resident confirmed receiving suppositories recently, despite not having frequent issues with constipation. The director of nursing stated that monthly audits were expected but had not received any from the nurse responsible for the area where the resident resided. The facility's medication administration policy did not include procedures for checking medication expiration dates prior to administration.