Expired Blood Glucose Control Solutions Used for Quality Control
Summary
A package containing two bottles of expired blood glucose (BG) control solutions was found stored inside one of the facility's medication carts. The bottles were labeled with a handwritten open date, and according to the manufacturer's instructions, the solutions expired 90 days after opening. Despite this, the expired solutions remained in the cart and were documented as being used for quality control checks after their expiration date. The Licensed Vocational Nurse (LVN) confirmed that the solutions should have been replaced once expired. The Director of Nursing (DON) acknowledged that expired blood sugar control solutions could result in inaccurate blood sugar readings. Facility policy required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, but this procedure was not followed in this instance. The expired solutions were available for use and had been used for quality control checks beyond their expiration date.
Plan Of Correction
C2030 COMPLETION DATE: 10/31/2025 C2030-Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/07/2025, the Charge Nurse immediately removed the expired Control Solution from Medication Cart 1. The DON immediately completed a one-on-one in-service with LVN 2 regarding p/p regarding viability of expired medications and biologicals, with an emphasis on the importance of possible effects on patient's safety and well-being. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of the expired Assure Dose Control Solution, DON, ADON, and RN Supervisor checked all medication carts and medication rooms for any additional expired medications and/or biologicals. No other expired products were identified. Ongoing random monitoring of medication cart reviews are done weekly by the RN supervisor, ADON, and DON while medication pass is in progress to ensure that no biologicals are present in medication cart. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, weekly random medication cart audits will be initiated and completed by the ADON and RN supervisor. Any observed issue will be corrected immediately, and findings will be reported to DON/Designee. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report to the QAPI/QAA committee and discuss findings of random weekly medication cart audits. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Penalty
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