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Based on observation, interview, and record review, the facility failed to remove expired drugs from stock.

This failure had the potential for patients to receive expired Intravenous (IV) solution (liquid injected into a person's vein) and could potentially have an adverse outcome.

Findings:

On February 7, 2024, at 10 a.m., an unannounced visit was conducted at the facility to conduct a revisit for a previous complaint validation survey.

On February 7, 2024, at 12:10 p.m., a tour of the Intensive Care Unit (ICU) Supply room was conducted. The following expired medications were observed:

-one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 01/23 (January 2023),

-one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 05/23 (May 2023), and;

-one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 12/23 (December 2023).

On February 7, 2024, at 12:15 p.m., an interview with the Director of ICU (D-ICU) was conducted. The D-ICU stated the expectation for the unit is not to have any expired medications available for use. She stated Supply Chain Staff checks expiration dates when they stock the unit. The D-ICU stated the drugs should have been removed from patient availability. The D-ICU stated if expired, the item should be removed from the supply room.

On February 7, 2024, at 12:20 p.m., an interview with the Director of Supply Chain (DSC) and the Materials Handler (MH) was conducted. The MH stated he is responsible for checking expired items in the ICU supply room. He stated he checked expiration dates when refilling that item. He stated the 5% Dextrose Lactated Ringers IV Solution should not be expired. He further stated any expired products should be removed from the supply room and disposed. He stated there should be no expired products available for use in the supply room.

A review of the policy and procedure (P&P) titled, "Disposal of Containers of Empty, Discontinued, or Expired Medications," dated August 8, 2022, was conducted. The P&P indicated, "...To provide for appropriate disposition of medication...Medications that are discontinued, unused, deteriorated, or expired will be disposed of appropriately..."