Expired Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with regulatory requirements, specifically by not removing expired medication from a medication cart. During an observation and interview, it was found that a medication cart on A Hall contained an individual medication card with 15 tablets of APAP/Codeine 300-30mg that had expired 10 days prior. The medication was stored in a locked compartment, but had not been removed from use. The responsible RN confirmed the medication was expired and stated she had not administered any of the expired tablets. She also indicated she was trained to check for expired medications and maintain the cart free of such items. The DON stated that expired medications should not be present in medication carts or rooms and that nurses are expected to check for and remove expired medications during each shift. Review of the facility’s control drug record showed the medication was last administered prior to its expiration, and pharmacy monthly reviews did not identify the expired medication for removal. Facility policy requires that outdated drugs be returned to the pharmacy or destroyed, but this process was not followed in this instance.