Improper Storage and Failure to Discard Expired and Unidentified Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of four medication carts and one of two medication rooms. During an observation of the medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 was found for a resident who was no longer using that medication and was currently taking Ozempic instead. The facility’s own policy, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that medications be stored in a clean, safe, and sanitary manner. Record review showed the involved resident was an older female with multiple diagnoses, including major depressive disorder, mixed hyperlipidemia, unspecified polyneuropathy, gout, and an unspecified muscle disorder. Her MDS indicated she was cognitively intact with a BIMS score of 14 and required partial to moderate assistance with several ADLs, while being dependent on staff for showers. She reported receiving her medications and not missing doses, and stated she was now taking Ozempic instead of her prior diabetic medication, though she did not recall the previous medication’s name. Additional observations on the medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill, with no label or resident identification. The DON, who did not know what the pill was or why it was left there, discarded the medications. In interviews, the ADON, DON, and a med aide each stated that nurses and medication aides were responsible for discarding expired medications into designated destruction bins, and that narcotics were handled separately with the pharmacy consultant. They acknowledged that medications should not be left loose or in unlabeled cups in the cart and that expired medications should have been discarded, but they were unable to explain why the unknown pill and loose pills were present in the cart or why the expired Humalog remained in the refrigerator.
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