F0761

D

Expired IV Antibiotic in Automated Dispensing Machine Prevents Timely Administration

Aurora, Illinois Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications stored in its automated medication dispensing machine were not expired, resulting in an ordered IV antibiotic dose being unavailable for administration. A resident developed an elevated temperature of approximately 100.2–100.4°F, and the resident’s daughter, who is also a nurse practitioner, requested that an IV antibiotic (Imipenem-Cilastatin 500 mg) be started immediately. A physician order was entered for Imipenem-Cilastatin IV 500 mg once daily for febrile illness, with the first dose scheduled for administration at 6:00 AM. The Medication Administration Record documented the scheduled dose with a notation to see progress notes, and subsequent progress notes and eMAR entries indicated that the medication was “not available” at the time it was due.

The DON reported that the dose of Imipenem-Cilastatin available in the facility’s medication dispensing machine was expired and therefore could not be administered when ordered. The DON stated that the pharmacy is responsible for maintaining the automated medication storage system, including tracking medication expiration dates and performing monthly inventory and outdating, as outlined in the facility’s Automated Medication Storage System policy. The DON also stated that facility staff do not have the ability to check expiration dates until a nurse pulls the medication from the machine, and that she did not contact the pharmacy regarding why an expired antibiotic remained in the machine. Because the ordered antibiotic was expired and not immediately usable, the resident could not receive the scheduled morning dose from the dispensing machine and was later sent to the emergency room at the request of the resident’s daughter.