HospitalInspections.org

Based on observation, interview, and review of the hospital's policy, the hospital failed to follow their policy of dating multi-use medication vials when opened. Failure to follow the policy had the potential for expired or outdated medications to be used. The failed practice had the potential to affect the 13 acute care patients on the census.

Findings Include:

During the tour on 12/04/18 at 1:30 PM of the hospital pharmacy, with the Pharmacy Supervisor, three opened multi-use insulin (a medication given to help regulate the amount of sugar in the blood) vials were observed in the pharmacy's refrigerator. None of the vials had documentation of an open date on the bottles.

During an interview on 12/04/18 at 1:45 PM, the Pharmacy Supervisor stated, "the nurses don't always date the vials when they open them."

Observation on 12/05/18 at 4:50 PM of the hospital pharmacy, with the Director of Nursing (DON), showed one open multi-use vial of insulin not dated, and one open multi-use vial of tuberculin serum dated 11/03/18 in the pharmacy's refrigerator.

Observation on 12/06/18 at 9:15 AM of the hospital pharmacy, with the DON and Pharmacy Supervisor showed two open multi-use vials of insulin, undated.

During an interview on 12/06/18 at 9:15 AM, the DON stated, "the vials should be dated when opened and it's nursing 101 to date opened vials." The DON further stated the tuberculin serum (an injection used to aid in the diagnosis of tuberculosis, an infectious bacterial disease) vial should have been discarded on 12/03/18.

Review of the hospital's policy titled, "Monitoring Scheduled Medications," last revised 10/24/17, under "Procedure" #11 showed, "Any multiple dose vial needs to be dated and initialed when opened. Multiple dose vials are good for 28 days once opened." Item #12 indicated, "Insulin vials and insulin pens are to be discarded 28 days after the first use."