Failure to Remove Discontinued Medication from Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that discontinued medication was promptly removed from a medication cart. Specifically, Lorazepam (Ativan) prescribed to a resident was discontinued on 09/19/25, as documented in the resident's electronic order summary and Medication Administration Record. Despite this, the medication remained on Medication Cart #1 as observed on 09/25/25. During interviews, an LVN acknowledged the medication should have been removed and recognized the risk of discontinued medication remaining accessible. The DON Trainee was unfamiliar with the facility's policy but stated that discontinued drugs should be removed and destroyed quickly. The ADON explained that discontinued medications were typically given to the DON, who was on leave, and that nurses continued to count the medication until the DON returned, as only the DON had access to the narcotic closet. The facility's policy required that outdated or discontinued medications be immediately removed from stock and disposed of according to established procedures. However, the continued presence of discontinued Lorazepam on the medication cart indicated a failure to follow this policy. The ADON stated that there was no risk as the medication was still being counted, but this contradicted the facility's written procedures and the understanding of other staff members. The Administrator Trainee was also unaware of the specific risks or policies regarding discontinued medications.