Expired, Unlabeled, and Undated Medications in Storeroom and Med Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management related to labeling, dating, and removal of expired drugs and biologicals. In the North Hall medication storeroom, an unopened single-use vial of Arexy RSV vaccine dispensed for a specific resident was found in the refrigerator with a manufacturer’s expiration date that had already passed, indicating it was kept beyond its expiration. A compounded IV bag of 0.9% sodium chloride with cefazolin for another resident was also stored past the pharmacy-labeled stop date and discard-after date. Additionally, a stock box of hemorrhoidal suppositories, a stock box of nicotine transdermal patches, two opened stock bottles of 500 mg Vitamin C tablets, and an unopened bottle of sore throat spray were all found on storeroom shelves with manufacturer expiration dates that had already passed. The surveyors further observed failures to properly date multi-dose medications to determine shortened expiration periods. In the medication storeroom refrigerator, one opened multi-dose vial of Tuberculin PPD injectable solution dispensed from the pharmacy had no label or box notation indicating the date it was opened, preventing determination of its 30‑day post‑opening discard date. A second opened multi-dose vial of Tuberculin PPD had an auxiliary pharmacy sticker indicating an open date and corresponding shortened expiration date, but the first vial lacked this required information. These findings showed inconsistent practices in documenting open dates for medications that require shortened beyond‑use dating. On North Hall Medication Cart #2, surveyors found an opened 6‑ounce bottle of sore throat spray that was not labeled with any resident’s name, and the med aide assigned to the cart could not identify which resident it belonged to; the bottle also bore a manufacturer’s expiration date that had passed. The same cart contained a bottle of lactulose solution dispensed for a resident, with pharmacy labeling that included a stop date and a “discard after” date that had already elapsed, indicating the medication was expired but still stored on the cart. During interviews, facility leadership acknowledged that responsibilities for monitoring expiration dates in the storeroom and on med carts had been assigned to specific staff, and that concerns about medication storage had been previously discussed.
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