F0761

E

Unsecured and Improperly Managed Inhaler Medications on Crash Cart

Brookfield, Wisconsin Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure medications were stored securely and that expired medications were removed from active use and discarded appropriately. During a review of crash carts with the Assistant Director of Nursing (ADON), three packs of Tiotropium Bromide Monohydrate inhalation powder labeled with Resident 16’s name, with an expiration date of 01/2027, were observed sitting on top of an unlocked, unsecured crash cart on 2 South. One of the inhalers had been used and had a use-by expiration date of 08/21/25. The ADON acknowledged at the time of observation that these medications should not have been left unsecured on the crash cart and stated that there was a designated medication room for expired medications where such inhalers should have been placed for pharmacy retrieval and disposal.

Review of the facility’s January 2018 policy titled “Medication Storage in the Facility” showed that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that all expired medications must be removed from the active supply and destroyed in the facility in the usual manner. The observed unsecured storage of labeled inhalers on the crash cart and failure to follow the process for handling expired medications were inconsistent with this written policy.