Undated Multi-Dose Injectable Medications and Expired Tablets Found on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices involving multi-dose injectable medications and an oral proton pump inhibitor. On the 100-hall medication cart, an open and undated multi-dose vial of semaglutide was found. Manufacturer instructions for semaglutide indicated that multi-dose pens must be discarded 56 days after opening. The nurse assigned to that cart stated that nurses working the carts were responsible for discarding open and undated multi-dose vials and that, per training and competency, every nurse should place the date of opening on multi-dose vials. She acknowledged she had not checked the date of opening on the semaglutide vial in her cart at the beginning of her shift, though she reported she had not administered any open and undated medication during that shift. On the 300-hall medication cart, surveyors observed one open and undated insulin glargine pen and one open and undated semaglutide pen, despite manufacturer instructions requiring insulin glargine pens to be discarded 28 days after opening and semaglutide pens 56 days after opening. In the same cart, a half-empty container of omeprazole 40 mg tablets was found with an expiration date of 1/11/25, indicating the medication was expired. The nurse assigned to this cart stated that nurses were responsible for discarding open, undated, or expired multi-dose vials and confirmed that training required dating multi-dose vials upon opening. She admitted she had not checked the dates of opening for the insulin glargine and semaglutide pens or the expiration date of the omeprazole at the beginning of her shift, though she reported she had not administered expired medication during that shift. The DON later stated that nurses were responsible for checking opening and expiration dates at the start of their shifts, and the Administrator stated there should be no expired medications left in the carts.
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