Expired Compounded Medication Administered via Enteral Tube
Penalty
Summary
A resident with a history of stroke with aphasia, gastrostomy tube feeding, and gastroesophageal reflux disease (GERD) was administered an expired compounded medication, Pantoprazole Sodium Oral Suspension, via enteral tube for nine days, totaling eighteen doses. The medication, which had a shortened expiration date due to its compounded nature, was stored in the medication cart and not checked for expiration prior to administration. The error was discovered after the resident had already received the morning dose, prompting notification of the responsible party and subsequent transfer to the emergency department for evaluation. The resident was found to have no acute complaints or adverse effects from the expired medication and was discharged back to the facility. The deficiency was identified through review of medication administration records, interviews with staff, the consulting pharmacist, and the physician. The consulting pharmacist confirmed that compounded medications have a short shelf life and require close monitoring of expiration dates. The physician stated that while no adverse effects were expected, nursing staff are required to ensure that expired medications are not present or administered. The incident was brought to the attention of facility leadership several months after it occurred, following a grievance filed by the resident's responsible party.