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Tag No.: A0724
Based on review of facility policy and procedures, observation of 6 Tower patient care unit, review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure monthly inspections of Emergency Code Carts were conducted according to facility policy.
Findings include:
Review on January 8, 2018, of facility policy and procedures "Code Cart Inspection and Stock Replacment Program," effective November 16, 2017, revealed "II ... It is the policy of the Department of Pharmacy Services to inspect monthly the contents of the Code Carts throughout the Medical Center in order to ensure that all medications contained within these carts are in authorized dosage formulations, delivery systems, and quantities as approved by the Life Support committee and the Medical Staff. It is also the policy to ensure that all medication in the carts are within their labeled expiration dates."
1) Observation on January 3, 2018, at approximately 1:15 PM of the Emergency Code Cart located on the 6th Tower patient care unit revealed a label on the cart with the last documented inspection dated June 27, 2017, and documentation of the earliest drug expiration date as November 1, 2017. Further observation of the contents of the emergency code cart revealed vials of Naloxone [emergency medication for drug overdose] were expired in November 2017 and vials of Amiodarone [cardiac medication] were expired in September 2017.
2) Review on January 8, 2018, of facility documents " ... Medication Storage Area Inspection Log," dated January 2017 thru December 2017, revealed no documented evidence that Medication Storage Area Inspection Forms were completed in July 2017, September 2017 and October 2017 for the following patient care units: North Tower 5, North Tower 6S, North Tower 6, North Tower 7 and North Tower 8.
3) Review on January 8, 2018, of facility documents " ... Medication Storage Area Inspection Log," documents dated August 2017 revealed no documented evidence that medication storage area inspection forms were completed for the following patient care units: North Tower 5, North Tower 7, North Tower 8, Levy 7 West, Levy 6 West, Levy 6 East, Levy 5 West, Levy 5 East, Levy 4 West, Levy 4 East and 2 TIP Moss.
4) Review on January 8, 2018, of facility documents " ... Medication Storage Area Inspection Log," dated November 2017 revealed no documented evidence that medication storage area inspection forms were completed for the following patient care units: ICU4A, ICU4S, CCU5A, CCU5C, CCU5S.
5) Interview with EMP1 on January 3, 2018, at 1:20 PM confirmed medications in the emergency code cart located on the 6 Tower patient care unit were expired and that Pharmacy staff was responsible for monthly inspections for expirations of the Emergency Code Cart medications.
6) Interview with EMP10 on January 8, 2018 at 11:46 AM confirmed no documented evidence that Medication Storage Area Inspection Forms were completed for the above patient care units on specified dates. Further interview with EMP10 confirmed that Pharmacy staff was responsible for completion of the Medication Storage Area Inspection Forms monthly for each patient care unit.