Improper Labeling and Failure to Discard Expired Tuberculin Vials in Medication Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices related to labeling and discarding multi-dose vials. Review of the facility’s Pharmacy Services policy, last reviewed December 31, 2025, showed that all opened multi-dose vials were required to be dated at the time they were opened. Product information for tuberculin skin testing solution indicated that the solution expires 30 days after the initial puncture into the vial. During observation of the first floor medication room with a staff member on January 21, 2026, surveyors found two opened vials of tuberculin skin testing solution, one without any open date and another labeled with an open date of December 4, 2025, which was beyond the 30‑day use period. In an interview, the DON and Assistant DON acknowledged that multi-dose vials should be dated when opened and confirmed that the vial dated December 4, 2025, was expired and should have been discarded. No specific residents or their clinical conditions were mentioned in relation to this deficiency. The findings were limited to the medication storage and labeling practices in one of two medication rooms observed (the first floor medication room), where the presence of an undated vial and an expired vial of tuberculin skin testing solution demonstrated noncompliance with the facility’s own policy and accepted professional standards for medication labeling and expiration dating.
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