Expired Medications and Improper Vaccine Storage Identified
Penalty
Summary
Surveyors identified several deficiencies related to the storage and management of drugs and biologicals in the facility's medication room. During an observation, eight unopened bottles of magnesium citrate were found to be expired and still present on the bottom shelf of the medication storage room. The expiration date on all bottles was confirmed to be past due, and both the DON and Administrator acknowledged that expired medications should not be available for use and should have been discarded. The DON stated that nursing staff were responsible for weekly checks for expired medications, but this process was not followed as required. Further deficiencies were noted in the storage and monitoring of influenza vaccines. The facility had two refrigerators containing Seqirus influenza vaccines, and temperature logs revealed that temperatures were not being recorded twice daily as recommended by the manufacturer. For multiple months, temperatures were only recorded once daily on a limited number of days, with many days missing any temperature documentation. Although the recorded temperatures for September and October were within the recommended range, the lack of consistent monitoring did not meet manufacturer guidelines. In November, the only recorded temperatures were below the recommended range, and there were significant gaps in documentation. Interviews with the DON, Administrator, and Consultant Pharmacist confirmed that staff were expected to record refrigerator temperatures twice daily and report any out-of-range readings. However, the DON was unaware of the incomplete logs and temperature deviations, and the Administrator could not explain why the process was not followed. The Consultant Pharmacist emphasized the importance of proper temperature monitoring and reporting, especially when temperatures fall outside the recommended range.