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Based on observation, document review, and interview it was determined the facility failed to ensure expired medications were not available for patient use.

The Findings Include:

1. On 10/28/24 at 11:30 AM, during a tour of the emergency department the following medications were found to be expired:
-1 of 1 Protamine Sulfate 250 mg/25 ml - 10 mg per ml (single dose vial) - expiration date 09/24.
-1 of 1 Norepinephrine Bitartrate 4 mg/4 ml - expiration date 8/24.
-2 of 2 Neomycin and Polymyxin B Sulfates and Gramicidin Ophthalmic Solution - 10 ml each - 1 bottle expiration date 8/24, and 1 bottle expiration date 9/24.
-1 of 1 Embroil for oral suspension 250 mg/5 ml - expiration date 8/24.
-5 out 5 Nabumetone 500 mg/1 tab, expiration date 3/31/24.
-1 of 1 Torsemide 100 mg/1 tab - expiration 4/24.

2. An undated Policy titled, "Outdated Drug Control" was reviewed. The policy included, "Policy: Outdated drugs will be removed from stock and will either be returned for credit or properly disposed of. Purpose: Extreme care must be exercised that no outdated medications are dispensed for patient use or allowed to remain in the dispensing area of the Pharmacy or in other medication areas. Procedure: ... 2. The Pharmacy personnel will constantly check all medication physically for dated items and remove all outdated ..."

3. An interview was conducted on 10/30/24 at 12:43 PM with E #6 (Pharmacist). E #6 stated they "do not audit every single medication in the Omni-cell dispensary machine every month. We noted there was a discrepancy with the expiration reports and medications that were not showing they were expired. We have been working on this since August."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on Novemeber 6, 2024, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on November 6, 2024, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.