HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure an accurate accounting of expired medication prior to removing medication from the facility. Findings include:

1. Observation and interview on 3/14/23 at 2:30 p.m. in the pharmacy with pharmacist C regarding the accounting of returned expired medication revealed:
*A sealed box had been on a chair in pharmacy.
-The box contained expired medication that required shipping.
*She had removed the medication from the Pyxis (automated medication dispensing system) and placed them in a tote in an unlocked cabinet in the pharmacy.
*There was a quantity report of the medication removed from the Pyxis system.
*She boxed up the expired medications once the tote in the unlocked cabinet had been filled.
*She had not reconciled the medications removed from the tote in the unlocked cabinet before placing the medications in a shipping box and sealing it for return.
*She received an invoice from the receiving facility for the expired medications.
*She had no way to compare the received medications against the sent medications.
*She would have reviewed camera footage from the two pharmacy cameras if there had been a discrepancy.
*Nursing staff were able to access the pharmacy if a medication had not been available in the Pyxis system.
-Staff would have used their name badge to access the pharmacy.
*Auditing of staff access would have been available for any medications discrepancy.

Interview on 3/14/23 at 3:00 p.m. with registered nurse D and director of nursing (DON) B regarding nursing staff accessing the pharmacy for medication revealed:
*All nursing staff had access to the pharmacy using their name badge.
*The medication would have been signed out and a sample medication would have been left on the counter in pharmacy for verification by the pharmacist.

Interview on 3/15/23 at 2:00 p.m. with DON B regarding pharmacy reconciliation of expired medication revealed:
*She was not aware the pharmacist had not reconciled the return of expired medications.

Interview on 3/15/23 at 2:15 p.m. with administrator A regarding pharmacy reconciliation of expired medication revealed the pharmacy had not had an accurate reconciliation of the expired medications that required shipping.

Review of the provider's August 2021 Expired Medication policy revealed:
*All non-controlled medication would have been stored separately from other medication.
-Expired medications would have been stored in a labeled container.
*When the storage of expired medications had been full the pharmacy would contact the purchaser for their return and disposal.