F0755

D

Expired PRN Narcotic Left on Medication Cart

Arlington, Texas Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically by not removing an expired Tylenol with Codeine #3 (acetaminophen-codeine 300-30 mg) tablet from a medication cart. A male resident with intact cognition (BIMS score of 15) and diagnoses including muscle weakness, anxiety disorder, depression, seizures, and PTSD had an active physician order for Tylenol with Codeine #3, one tablet by mouth every six hours as needed for pain. His care plan identified him as being at risk for alteration in comfort related to seizures and history of falls, with interventions including pain medications as ordered. During an observation of the 300 hall medication cart, surveyors found that this resident’s Tylenol with Codeine #3 had expired earlier in the month and remained available on the cart.

Multiple staff interviews confirmed that nurses and medication aides were responsible for checking medications to ensure none were expired, and that expired medications, particularly narcotics, were to be removed from the cart immediately and given to the DON for proper disposal. LVN A, RN B, the ADON, and the DON each stated they were unaware that the resident’s Tylenol with Codeine #3 was expired and acknowledged that expired medications should not be present on the cart. The ADON and DON reported that ADONs audited medication carts weekly and the consultant pharmacist audited carts every other month. The facility’s Medication Storage policy, revised 10/2023, stated that outdated medications are to be immediately removed from stock and disposed of according to destruction procedures and reordered if a current order exists, which was not followed in this instance.