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Based on observation, interview, and record review, the facility's pharmacy services did not meet requirements, or follow their facility policy to ensure that outdated drugs and biologicals were not available for patient use, in 2 of 3 (Emergency Department and Medical/Surgical Unit, 5th Floor), patient care areas toured on 09/12/12.

Findings included:

During tours on 09/12/12, the surveyor observed the following expired and/or unusable drugs and biologicals, that had been available for patient use in 2 of 3 patient care areas:

Patient Care Area #1: Emergency Department

2:15 PM: Pediatric Breslow Crash Cart:
2 - Mannitol injectable, 12.5 grams/50 milliliters (ml.), expired 09/01/12, and was located in the sealed "Pediatric Crash Cart Drug Tray," marked as the first to expire drug.
1 - Lactated Ringer's intravenous fluid (IVF), 500 milliliters (ml.), expired 07/12.
1 - 0.9 % Normal Saline IVF, 500 ml., expired 05/12.

2:45 PM: Nurse's Station:
5 - Pediatric BacT/Alert blood culture bottles, expired 08/19/12.

Dental Box in Nurse's Station:
1 - Peridontal Dressing set (2 tubes), expired 03/07.
1 - Benzo-Jel 1 ounce (oz.), expired 12/11.
1 - Ora5 Topical Bacterial agent, 1 bottle, expired 02/10.
1 - Temrex, temporary cement, 1 fluid oz., expired 05/13/11.
1 - Dycal Dentin, expired 08/11.

In an interview at 2:45 PM on 09/12/12 with Personnel #12, he verified the above drugs and/or biologicals were expired and available for patient use.

Patient Care Area #2: Medical/Surgical (M/S) Unit, 5th Floor:

3:45 PM: Crash Cart:
2 - Dextrose 5% Water (D5W), 250 ml., expired 07/12.

In an interview at 3:45 PM on 09/12/12 with Personnel #11, she verified the above biologicals were expired and had been available for patient use.

The facility's Pharmacy "Expired Drugs" policy, last reviewed 01/11, noted that "expired drugs shall be checked at the beginning of each month...all clinical areas where drugs and IV (intravenous) fluids are kept are to be checked on a monthly basis and must be removed from the area at least 2 months prior to the expiration date." The policy also noted that "when removing expired drugs from the pyxis or other floor stock areas, a report must be generated from the pyxis and the drugs listed must be replaced in the pyxis," and that "expired IV fluid must be discarded and added to the reorder list so that it can be replaced,"and "IV fluids must be checked in the pharmacy, crash carts and pyxis machine and must be replaced as stated above."

The facility's Clinical "Emergency Carts-Defibrillators" policy, dated 06/09, noted that "Medication trays and numbered locks are controlled by Pharmacy," and "Pharmacy will check the carts for expiration dates, proper drug storage, stock level, and unit inspection log as determined by Pharmacy policy."

Based on observation, interview, and record review, the facility did not meet requirements or follow their Emergency Cart policy, to ensure that supplies and equipment had been maintained for an acceptable level of safety and quality, in that, expired supplies and/or equipment had been available for patient use in 3 of 3 (Operating Room, Emergency Department, and Medical/Surgical Unit, 5th Floor), patient care areas.

Findings included:

During tours on 09/12/12, the surveyor observed the following patient care areas where expired supplies and/or equipment had been available for patient use:

Patient Care Area #1: Operating Room:

10:15 AM: Hall Crash Cart:
1 - Culturette, expired 07/12.
In an interview at 10:15 AM with Personnel #15, she verified the above expired supply.

Patient Care Area #2: Emergency Department (ED):

2:00 PM: Room #2:
2 - Pain Trays, expired 05/31/12.

2:15 PM: ED Crash Carts:
Pediatric Breslow Crash Cart:
1 - Arterial Blood Gas (ABG) Kit, expired 05/11.
Intra-Osseous Kit (on top of Brasilow Cart):
1 - Intra-osseous needle, 15 gauge, expired 07/08.
Adult Crash Cart:
2 - Angel Wing luer lock intravenous (IV) safety set, expired 04/12.
1 - 22 French Nasopharyngeal airway, expired 12/11.
1 - 20 French Nasopharyngeal airway, expired 08/12.
1 - Mini-Tracheostomy kit, expired 06/12.

3:15 PM: ED Medical Screening room:
1 - 2.0 Ethilon sutures, expired 07/11.
1 - Bioclusive dressing, expired 02/11.

In an interview at 3:15 PM on 09/12/12 with Personnel #12, he confirmed the above supplies and equipment in those ED areas were expired, and had been available for patient use.

Patient Care Area #3: Medical/Surgical (M/S) Unit, 5th Floor:

3:45 PM: Adult Crash Cart:
1 - 22 French Nasopharyngeal airway, expired 07/12.
1 - 20 French Nasopharyngeal airway, expired 08/12.
1 - Spinal needle, expired 08/12.
1 - ABG kit, expired 07/12.

4:45 PM: M/S Unit, 5th Floor:
6 empty Patient Rooms (501, 504, 511, 514, 516 & 518) toured, with 5 of 6 noted below:
Rooms #501, #504. #511, and #514, each contained:
1 - Adult Ambu bag, expired 03/12.
Room #516 contained:
1 - Adult Ambu bag, expired 08/12.

In an interview at 4:45 PM on 09/12/12 with Personnel #11, she verified the above supplies and equipment were expired and available for patient use.

Review of the facility's Clinical "Emergency Carts-Defibrillators" policy, dated 06/09, noted that their policy is "to ensure a properly stocked emergency cart...," and "a licensed staff member (RN, RT, PT, etc.) as designated by manager is responsible for checking the crash cart,"and "all carts will be opened and checked for contents once monthly and following each use...sterile items will be checked for integrity and expiration date...items with expiration dated expiring within the month will be replaced."