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ST JAMES HOSPITAL
STANDARD TAG FOR OUTPATIENT SERVICES
Tag No.: A1081
Based on policy review, observation, and interview, the facility failed to remove expired medication from the medication room for four of four epinephrine pens.
Findings include:
Review of the policy "Unstable and Outdated Drugs," last reviewed November 2023 revealed that all outdated drugs shall be returned to the pharmacy department for proper disposal. Nursing or other staff approved by licensure to administer medications, will contact the Pharmacy Department if outdated drugs are discovered. The nursing or other licensed staff member will place the unusable medication in an area away from usable medications and label it to return to the pharmacy.
Observation on 03/11/24 at 01:15 PM in the Urgent Care Unit medication room drawer revealed two Epinephrine Auto Injectors 0.15 mg with an expiration date of August 2023. There were two Epinephrine Auto Injectors 0.3mg with an expiration date of October 2023.
Interview on 03/12/24 at 02:45 PM with Staff (O) Chief Nursing Officer, revealed that a nurse should have recognized the expired medication and removed them.