HospitalInspections.org

Based on observation, review of documentation, and interview with staff, the facility failed to ensure that policy requirements for monitoring outdated drugs and supplies were followed. Expired medications and supplies were found in 4 patient care areas available for patient use, which could potentially result in patients receiving medications and/or supplies that are ineffective and/or non-sterile.

Findings were:

The facility policy and procedure, entitled Expired Medications and Supplies, last approved in January 2013, states that medications and supplies will be periodically checked for outdates and replaced as needed.

A tour of the facility was conducted the afternoon of 4/8/2013 in the company of the Director of Nursing, Staff #15. In the Emergency Department (ED) trauma room, outdated supplies were found, including 4 airways which expired in June 2011; 4 fluid warming tubing packages which expired in November 2011; and 3 nasal sponges which expired in March of 2012. In the Respiratory Department, 3 jars of fixative solution were found with an expiration date of December 2012. During a separate tour conducted the morning of 4/9/2013 in the company of Staff #15, expired medications were found in the hospital's clinic and expired supplies were found in the Surgery Department's endoscopy suite. In the clinic, 21 packages of expired medications samples were found: One package expired in April 2012; 1 in May 2012; 2 in July 2012; 1 in October 2012; 1 in November 2012; and 1 in December 2012. Additionally, 10 packages of medications were found which expired in February 2013 and 4 packages expired in March 2013. In the endoscopy suite, 4 polyp traps were found which had expired in February 2010.

In-person interviews were conducted with Staff #15 during the afternoon tour of the facility on 4/8/2013 and during the morning tour of the clinic and surgery suite on 4/9/2013. Staff #15 verified that expired medications and supplies were found available for patient use in 4 patient care areas, including ED, Respiratory Department, clinic, and the endoscopy suite.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that the nutritional needs of inpatients were met in accordance with recognized dietary practices as temperature readings of the nourishment refrigerator in the nursing station were not obtained on a daily basis. This was in violation of facility policy and potentially could have resulted in unsafe temperatures not being detected.

The findings were:
The facility policy entitled "Temperature Records" dated 12/97 was reviewed on 4/8/13 and reflected in part "Policy: Temperature readings for freezers, refrigerators, and dishmachines will be obtained on a daily basis and recorded on the temperature log sheet. Procedure: The temperature of the freezers, refrigerators and dishmachines will be recorded by the 6:30 am cook on a daily basis."

During a tour of the dietary department on the afternoon of 4/8/13 in the company of staff # 18, temperature log sheets were reviewed. There were no temperatures recorded for the nursing station nourishment refrigerator and freezer on the following dates: 1/27-31/13; 3/28-31/13; 4/1/13; and 4/4-5/13. These findings were confirmed in an interview with staff # 18 on 4/8/13 at 3:20 pm.