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Based on observation, interview, review of facility Audit Tools and the facility's policy, it was determined the facility failed to store drugs according to policy related to an expired vial of medication and medication vials available for use in the drugs cabinet that were undated and not initialed.

The findings include:

Review of Nursing Practice Guidelines titled, Discarding and Storage of Medications, dated 07/27/12, revealed the Pharmacy will check medications for stock amount, outdates, etc per Pharmacy Policy. Emergency Department (ED) staff will also check medication located in the Emergency Department for outdates. Multi-dose vials are to be dated and initialed upon initial needle puncture. All multi-dose vials shall be discarded within 28 days of needle puncture or immediately upon expiration if sooner than 28 days. Any multiple dose vial found open without a date and initials should be considered unusable and discarded immediately. All outdated drugs, overstocked medications, and those with worn containers, illegible labels or expiration dates shall be returned to the Pharmacy for disposition.

Review of a Pharmacy Policy titled, "Unit Inspection", dated January 2013, revealed the procedure for disposal of drugs that are out of date. All drug storage areas within the hospital will be inspected at least monthly. All out of date drugs are returned to the pharmacy for proper disposal. A pharmacy technician will direct the monthly inspection of all drug storage areas in the hospital. A written record of these inspections will be maintained. Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. Out of date drugs are destroyed on site, or returned to the vendor, the wholesaler, or a third party for credit or destruction with regard to State and Federal Law.

Review of the Monthly Medication System Audit tools, dated May 2013 through March 2014, revealed open medication vials in the ED were dated and initialed. The audit also revealed that outdated medications were not present in the ED. The audits were completed monthly by Pharmacy Technician #1.

Observation of the narcotic medication cabinet in the ED, on 03/11/14 at 1:30 PM, revealed a vial of Flumazenil, used as a benzodiazepine reversal agent, stored inside. The expiration date on the vial was 05/13.

Observation of the ED medication cabinet, on 03/11/14 at 1:35 PM, revealed open vials of Dexamethasone (a steroid), Kenalog (a corticosteroid) and Labetalol (an adrenergic receptor blocking agent) that were not initialed and dated. All had holes in the rubber and had been punctured.

Observation of the ED medication cabinet, on 03/11/14 at 1:35, revealed an open vial of Labetalol that was labeled 12/19 and initialed but was not discarded within twenty-eight (28) days after opening.

Interview with the ED Director, on 03/11/14 at 1:35 PM, revealed pharmacy was responsible for checking for medication outdates, as well as the ED staff before administering a medication. ED staff should have initialed and dated vials as they were opened and discarded them within twenty-eight (28) days.

Interview with Pharmacy Technician #1, on 03/12/14 at 9:15 AM, revealed the pharmacy staff reviewed medications throughout the building for outdates. They utilized a sticker system to alert staff of the month a medication was to expire.

Interview with the Director of Nursing (DON)/Chief Nursing Officer (CNO), on 03/13/14 at 10:25 AM, revealed pharmacy monitored for expired medications throughout the building. She expected staff to date and initial vials when opened and discard after 28 days.

Interview with the Administrator, on 03/12/14 at 12:41 PM, revealed he expected staff to adhere to policy. If something was expired, it needed to be dealt with. Supervisors should have enforced the facility's policies.

Based on observation, interviews, review of Food Temperature logs, review of the Job Description - AM (Dayshift) Food Production Manager, and review of the facility's policy, it was determined the facility failed to ensure cold hold food temperatures were taken, maintained at forty (40) degrees Fahrenheit or below prior to serving, and documented.

The findings include:

Review of the facility's policy titled, "Food Preparation and Food Temperature Checks and Documentation Procedures", not dated, revealed both AM and PM food production managers (cooks) are to conduct food temperature checks on previously cooked or ready to use foods every two (2) hours. These temperatures are to be documented (both shifts) on the posted food temperature log. Further review revealed the correct temperatures for cold hold/cold storage and refrigerated foods is forty (40) degrees Fahrenheit (F).

Review of the facility's, "Job Description - AM (Dayshift) Food Production Manager, revealed they were responsible for temperature checks and documentation on all potentially hazardous foods. These checks are to be taken and recorded every two (2) hours.

Review of the Certificate, dated 02/05/13, from the Biomedical Company that checks the cooling table revealed the cooling table "passed all tests".

Observation, on 03/12/14 at 12:00 PM of Cook #1 and the Dietary Supervisor, taking cold food temperatures on the tray line revealed the tomatoes temperature at fifty (50) degrees F, Banana cream pie at fifty five (55) degrees F, and a fruit cup of pineapple/oranges at fifty (51) degrees F.

Review of the Temperature Log, dated March 2014, "Dietary Department Food Temperature Monitor Dayshift only", revealed: on 03/12/14 meat and vegetable temperatures at 11:00 AM were completed with no cold hold food temperatures documented. Further review revealed no cold hold food temperatures were documented for dayshift in March. Further review revealed, on the bottom of the Log are CCP (critical control points) that state, Cold hold and refrigerated foods forty one, (41) degrees.

Interview with the Dietary Manager, on 03/12/14 at 12:15 PM, revealed cold food temperatures should be checked prior to putting out and she depended on the cooks to check the temperatures. The Dietary manager asked Cook #1 about the cold food temperature checks after she checked the temperature log with no documentation. Cook #1 told the Dietary Manager she did not check cold food temperatures on the tray line. The Dietary Manager immediately placed cold hold foods, tomatoes, banana cream pie and fruit cups back into the cooler.

Interview with Cook #1, on 03/13/14 at 9:35 AM, revealed she usually checked cold food temperatures, had got busy and forgot to do them. She stated the temperatures were to be checked every two (2) hours including cold foods and temperatures should be documented on the temperature logs. She revealed she brings out the cold foods between 11:00 AM and 11:30 AM, then starts the cart trays for patients and it goes out at 12:00 PM. She stated the cold foods are loaded first on the cart which is divided with a heated and cooling side. The cold food is brought out and when foods get low, she brings out more food. She revealed there is a refrigerated unit underneath the inset area and the cold food sets on it

Interview with the Dietary Director/Dietician, on 03/13/14 at 10:35 AM, revealed the cold food on the tray line sits on a cooling server/table with a refrigerator part underneath. She stated she did not know how cool that is, would check with maintenance to see if the equipment supplier checks the unit. She stated their policy on temperature checks is the food is checked when put out and every two hours. The cold hold food temperature should be less then forty (40) degrees Fahrenheit if the cooling table is doing its job. Temperatures should be documented by days and evening shifts for both hot and cold foods. Follow Federal food regulations less then forty (40) degrees Fahrenheit. All the CCP's are on the bottom of the temperature logs. Temperatures should have been documented and checked per the Dietary Supervisor to ensure they were being documented. Our cooks and anyone in the kitchen should know to check temperatures every two hours and what those temperatures should be. Cook #1 should have checked the cold food temperatures at 11:00 AM and if not at the correct temperatures, put back into the cooler and then checked again before serving. Our policy states to check temperatures on the line when you put the food out and every two hours to hold below forty one (41) degrees Fahrenheit for cold food. Staff get educated on the policies, read and signs, staff meetings, and in-services.

Interview with the Administrator, on 03/13/14 at 12:40 PM revealed he would expect temperatures for cold food on the tray line to be at or very close to forty one (41) degrees Fahrenheit. He stated he would expect the cooks to follow the policy to check temperatures and to document the temperatures.