Expired and Undated Medications Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to expired and undated medications on one of three medication carts reviewed (the Hall 200/300 cart). During an observation, the cart was found to contain a bottle of Nitroglycerin for Resident #15 with an expiration date of 12/22/2025 and a box of Ondansetron for Resident #33 with an expiration date of 12/07/2025, both of which remained on the cart past their expiration dates. The same cart also contained a Novolin 70/30 FlexPen for Resident #2 and a Lantus FlexPen for Resident #69 that had been opened but were not dated, contrary to expected practice for multiuse vials and pens. In interviews, RN-E stated that all multiuse vials should be dated when opened, that nurses are responsible for dating medications at first use and checking dates prior to administration, and that expired medications should be removed from the cart during routine checks. The DON similarly stated that all multiuse dose medications, including insulin, should be dated when opened by the nurse and checked each time before administration, and that expired medications should be removed from the cart immediately. She also acknowledged that the facility did not have a policy specifically addressing the dating of insulin or other multiuse dose medications, although the existing “Medication Access and Storage” policy required outdated, contaminated, or deteriorated medications to be immediately removed from stock, disposed of according to destruction procedures, and reordered from the pharmacy.
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