Improper Medication Storage and Failure to Remove Expired Drugs
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to improper medication storage and failure to remove expired medications. During an observation of a medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 and dated 12/26/2024 for a specific resident was found still stored. The DON later stated that this resident no longer used Humalog and was currently taking Ozempic instead. The facility’s policy on Medication Labeling and Storage, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. Additional observations on a medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill. The DON, when interviewed, stated she did not know what the pill was or why it was left there and discarded the medications. The DON also stated that staff should not keep medication in the cart in a cup with no label or have loose pills in the cart, and that medication carts should be clutter-free with expired medications removed. The facility’s policy required medications and biologicals to be stored in locked compartments under proper conditions, with nursing staff responsible for maintaining safe and sanitary storage and preparation areas. Interviews with the ADON, DON, and a med aide showed that responsibility for discarding expired medications and auditing medication carts and rooms was assigned to nurses and medication aides. The ADON stated that expired medications and medications for discharged residents were to be discarded in a designated destruction box in the medication rooms, and that narcotics were stored in a lock box in the DON’s office until destroyed with the pharmacy consultant. The DON and med aide each confirmed that nurses and med aides were responsible for throwing away expired medications and that everyone should receive their medications as ordered. Despite these stated expectations and procedures, the presence of an expired Humalog cartridge in the refrigerator and unidentified loose and cup-held pills in the medication cart demonstrated that the facility did not ensure all drugs and biologicals were stored properly and that expired or unidentified medications were removed as required.
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