Unlocked Medication Cart and Expired Medications on 400 Hall
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices related to securing and storing drugs and biologicals for all 20 residents on the 400 hall. During an observation of the 400 hall, the medication cart near the nurse’s station was found unlocked with no staff present, and an LPN confirmed that the cart was not secured and that it should always be locked. The facility’s failure to keep the medication cart locked meant that medications were not properly secured in accordance with requirements that drugs be stored in locked compartments. Surveyors also found multiple expired medications in the treatment and medication carts on the 400 hall. For a resident admitted on 08/08/23, a Breyna inhaler (160-4.5 mcg) stored in the treatment cart was observed to be expired as of December 2025. For a resident admitted on 06/24/10, ipratropium bromide and albuterol sulfate inhalation solution (0.5 mg/3 mg per 3 ml) in the treatment cart was expired as of 06/20/25. For a resident admitted on 02/03/23, an IPAT-ALUBUT UD0 0.5-3 MG/3AMPUL-NEB medication in the medication cart was expired as of 02/25. In interviews, the LPN stated that nurses are supposed to check medications daily for expiration and remove expired or discontinued medications to the designated medication room for disposal, and the DON confirmed that expired medications should not be in the carts and that nurses should check for expired medications each shift.
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