Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices during review of two of three medication carts. On the orchard hall medication cart, a prescription bottle of levothyroxine 200 mg was found in a large drawer with several small round pills remaining. The pharmacy label on the bottle showed a discard-after date of 1/4/25 and had “expired” written in pink ink, yet the medication remained in the cart instead of being removed from stock. When interviewed, an LPN stated she believed expired medications should be taken out of the medication cart. On the garden hall medication cart, surveyors found additional labeling and storage issues. In the first large drawer, a Humalog insulin pen was stored in a zip-lock bag with another lispro insulin pen; the bag contained a pharmacy label for the lispro pen, but the Humalog pen itself had no pharmacy label. In the fourth large drawer, a single dose of amoxicillin/clavulanate potassium in sealed manufacturer packaging was found loose in the drawer without a pharmacy label. Unit managers explained that the Humalog pen and the amoxicillin/clavulanate dose had been removed from the emergency drug kit (EDK), which does not provide pharmacy labels, and that nurses are expected to label such medications with the resident’s name, room number, and physician’s name at the time of removal. Another LPN indicated that if a pharmacy label comes off, the nurse should write the resident’s last name, provider’s name, and “see MAR” on the packaging. The facility’s medication storage policy requires that outdated drugs be immediately withdrawn from stock and that medications and biologicals be stored safely, securely, and properly.
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