Expired Lorazepam Vial Found in Medication Room Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication storage and monitoring when an unopened vial of Lorazepam 2 mg/mL with an expiration date of August 2025 was found in a locked bin in medication room [ROOM NUMBER]'s refrigerator. The observation occurred in the presence of a medication aide, who verified the expiration date on the vial. The report does not identify any specific resident associated with this medication or any clinical use at the time of the survey. During interviews, the medication aide stated she was unsure who was responsible for checking the medication room for expired medications and believed night shift staff only checked the refrigerator temperature. She also indicated that the Pharmacist visited monthly but needed to confirm details with the DON. The DON reported that the Pharmacist visits once per month to check for expired medications and that nurses are expected to remove discontinued medications from carts or the refrigerator and place them in pharmacy return containers. The Administrator stated that expired medications should be sent back to the pharmacy and that each nurse should check medication orders each shift and remove discontinued medications, as well as check carts for expired and discontinued medications before administering medications. The Pharmacist reported that he visits monthly for medication administration observations and that a team member visits every other month to check the medication room for expired medications and stock needs, and further stated that the facility should not rely on pharmacy visits to review medication stock for expired medications because pharmacy staff may not check the stock every month.
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