HospitalInspections.org

Based on policy and procedure review, observation, and staff interviews, hospital staff failed to ensure supplies were maintained at an acceptable level of safety and quality for 10 of 19 Sterile water, single dose vials observed.
The findings include:
Review of hospital policy 4/30/2015 revealed, "Expiration Dates and Shelf Life" with a revision date of 09/2012 revealed, "PROCEDURE: I. All Materials Handlers as well as the Inventory Control Clerk will be responsible for monitoring expiration dates and the shelf life of all stock items at (named hospital) Logistics Center. II. Expiration dates of all items are checked daily as supplies are put away and picked. III. Expired products will be segregated and notification will be sent to the Inventory Control Team immediately ... "
Observation of non-stock supplies in the Medication room on Unit 7-E April 29, 2015 at 0930 revealed ten (10) -10 milliliter (ml) unopened single dose vials of Sterile water with an expiration date of 4/1/2015. Observation revealed expired vials were not "segregated" as outlined in hospital policy, "Expiration Dates and Shelf Life."
Interview conducted 04/29/2015 at 0930 with RN # 1 revealed monitoring of expiration dates is a "team effort." Interview revealed the nursing staff check expiration dates of medications prior to preparation and administration and the "central supply clerk" checks same when stocking supplies. Interview revealed the unopened Sterile water vials were out of date. Interview with Nurse Manager # 1 and RN # 1 confirmed staff failed to follow the hospital "Expiration Dates and Shelf Life" policy. Interview confirmed the expired single dose vials should have been discarded.
NC 00105465