Expired Medications and Inadequate Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were discarded and did not maintain proper monitoring of medication refrigerator temperatures. During observations, surveyors found 25 expired heparin lock flush solutions with expiration dates ranging from 03/2023 to 07/2022 in the medication room, as well as expired Solosite wound gel, enema saline laxative, and zinc oxide ointment on the medication cart. All expired items were unopened but accessible for use. Additionally, one medication refrigerator lacked a thermometer, and temperature logs for both medication refrigerators on two units showed significant gaps in daily monitoring and documentation, with several days and even weeks missing entries. Interviews with nursing staff and the DON revealed confusion and inconsistency regarding responsibility for checking medication refrigerators and monitoring for expired medications. The night shift was reportedly responsible for these tasks, but there was uncertainty about staff training and clear assignment of duties. Facility policy required nursing staff to maintain medication storage areas and to contact the pharmacy for instructions on handling outdated medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and incomplete temperature monitoring.