F0755

E

Failure to Maintain E-Kits and Proper Medication Disposal Procedures

Los Angeles, California Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to maintain pharmaceutical services and emergency medication kits in accordance with facility policy and pharmacy agreements. At nurse station 2, an IM emergency kit contained a vial of bacteriostatic water 30 ml in slot 20 that had expired on 11/1/2025 and remained in the kit for 75 days past expiration. RN 1, who opened the locked medication room, acknowledged she had not checked the e-kit and stated expired medications could be contaminated and lose effectiveness. Across nurse stations 1, 2, and 3, RN 1 was unable to locate any e-kit logs, and LVN 1 stated there were no e-kit logs in the facility and that he did not consistently perform visual checks on the e-kits at nurse stations 2 and 3. The facility did not provide documentation that the 15 e-kits in the facility were checked every shift as required by the DON’s stated process.

The survey also found failures in the disposition and documentation of resident medications. Resident 4 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, cerebral edema, and atelectasis, and expired on 7/28/2025. On 1/14/2026, RN 1 located a white paper bag containing Resident 4’s medications on the top shelf of a cabinet in the locked medication room at nurse station 2. RN 1 stated that medications for discharged residents should be disposed of and documented on the Medication Disposition Record and Pass Log, but she could not locate these logs for nurse station 2. The DON later stated that medications of discharged residents should be destroyed within 90 days of discharge, while Resident 4’s medications remained in the facility for 179 days after discharge.

Record reviews of Medication Disposition Record and Pass Logs at nurse stations 1 and 3 revealed additional deficiencies in medication destruction practices. At nurse station 3, the log dated 10/13/2025 showed two medications documented as disposed of in waste management without a second licensed nurse’s signature as witness, contrary to facility policy requiring two licensed nurses to witness destruction of non-controlled medications. At nurse station 1, the log dated 10/19/2025 showed five medications documented as disposed of in a trash bin, which the DON stated was not an approved method of medication disposition, and these entries also lacked a second nurse’s witness signature. The DON confirmed that the facility failed to follow its process for proper medication disposal and that e-kits were expected to be checked every shift to ensure emergency medications were not expired and kits were intact.