Expired Medications, Unlabeled Insulin Pens, and Loose Pills Found in Medication Carts
Penalty
Summary
Surveyors observed multiple deficiencies in medication storage and labeling practices across four medication carts. Expired Bisacodyl suppositories and Omeprazole tablets were found in medication carts and available for use, indicating that staff failed to remove expired medications in accordance with manufacturer expiration dates. Additionally, unidentifiable loose pills of various shapes and colors were discovered in the drawers of two medication carts, with staff unable to identify or provide expiration information for these medications. Interviews with Certified Medication Aides (CMAs) and nurses revealed inconsistent practices regarding checking for expired or loose medications, with some staff stating they typically checked at the end of their shift or had not yet had time to inspect the carts. Supervising nurses confirmed the presence of expired and loose medications and acknowledged that these should have been discarded. Further deficiencies were noted in the handling of insulin pens. Two opened insulin Glargine pens stored at room temperature were found without any opened date, contrary to manufacturer specifications that require dating upon opening and discarding after 28 days. Staff interviews indicated a lack of clarity regarding responsibility for dating insulin pens, with CMAs stating that nurses were responsible for this task. The Director of Nursing (DON) and the Administrator confirmed their expectation that all nursing staff follow medication storage guidelines, including dating insulin pens and timely removal of expired and loose medications.