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Based on observation of the facility's Surgery Department (Operating Room 8's Anesthesiologist's Medication Cart), interview with the facility's Operating Room Director and the Director of Pharmacy, the facility failed to ensure that expired medications were not available for patient administration with the potential that expired, ineffective medications could be used for patient care.

Findings:

Observation of the facility's Operating Room #8 Anesthesia Medication Cart on 1/12/12 at 10:15 a.m. revealed two vials of Nimbex (a paralyzing medication, used in surgery) 20 mg/10 ml had been removed from the refrigerator on 12/20/11 (this date had been marked on the lid of each of the vials). Review the drug manufacturer's label information and review of the facility's policy and procedure both indicated that this medication, must be discarded after 21 days from the time that it has first been removed from the refrigerator. Both of the Nimbex vials had been kept out of the refrigerator for 23 days, based on the dates on each lid (more than 48 hours beyond the time allotted to the facility to discard these vials).