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Based on observations, record review and interview, the hospital failed to remove expired medications from the patient medication room for one sampled patient (#51) out of 11 sampled patients and failed for two non-sampled (NS) patients (NS #1 and NS #2), to ensure that medication cups were labeled with information including the patient's name, in accordance with the Hospital's policy. Findings include:

Review of the Hospital's policy titled Expired/Damaged/Unusable Medications indicated that all expired, damaged, or unusable pharmaceuticals are to be returned to the Pharmacy Department for destruction or processing for return to manufacturer.

On 6/27/18 at 9:40 A.M., the Surveyor toured Unit 4 West located at the Haverhill Campus with Clinical Leader (Nurse #21). Upon entering Medication Room #1, the Surveyor observed medications in the blue bin next to the Pyxis machine (automated dispenser used for storage of medications). The Surveyor observed a 250 milliliter (ml) bag of 20% intravenous (IV) Fat Emulsion medication labeled for Patient #51. The Fat Emulsion's expiration date was 6/23/18 at 2:00 P.M. The Clinical Leader (Nurse #21) said that the blue bin was for pre-mixed IV medications intended for patient use.

When asked about Patient #51's Fat Emulsion medication, Clinical Leader (Nurse #51) said the Fat Emulsion expired on 6/23/18 and should not be in the blue bin for patient use. The Clinical Leader (Nurse #51) said the Fat Emulsion medication should be returned to the pharmacy and does not belong in Medication Room #1 because it had expired.



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2. The Hospital's policy, titled "Labeling of Medications, Medication Containers and Solutions", with a publication dated of 04/08/16, indicated that medications, medication containers, and solutions were labeled whenever medications were prepared but not immediately administered. The Policy defined a medication container as containers used to hold medication, including medicine cups. The Policy indicated that labeling should contain information including: the patient's name, medication name, medication strength/concentration, medication amount.

The Surveyor made observations of the secured medication room on the St. Dymphna's unit with Nurse #2 at 9:00 A.M. on 06/27/18. The Surveyor observed two clear medicine cups containing patient medications on top of a medication cart, as well as a 21 mg nicotine patch in packaging which identified the medication name and strength/concentration, but was not labeled to indicate which patient the patch was prescribed to. Nurse #2 said the medications should not be left on top of the medication cart. The Surveyor and Nurse #2 reviewed the contents of the medicine cups, which were identified as:

- One medicine cup contained three 150 milligram (mg) tablets of Lithium (a mood stabilizer). The patient's first name (NS #1) was written on the cup in black marker, but the cup was not labeled with the patient's last name or identifier, or the medication name, medication strength/concentration, and medication amount. The tablets were contained in packaging which identified the medication name and strength/concentration, but did not identify which patient they were to be administered to.

- A second medicine cup contained: one mg tablet of Benzotropine (a medication used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs); a 20 mg tablet of Lisinopril (a medication used to treat high blood pressure and heart failure); a 25 mg tablet of Metoprolol (a medication used to treat high blood pressure); an 850 mg tablet of Metformin (a medication used to control blood sugars); and, a 50 mg tablet of Sertraline (an antidepressant medication). The patient's first name (NS #2) was written on the cup in black marker, but the cup was not labeled with the patient's last name or identifier, or the medication name, medication strength/concentration, and medication amount. The tablets were contained in packaging which identified the medication name and strength/concentration, but did not identify which patient they were to be administered to.

The Surveyor interviewed Nurse #20 at the time of the observations. Nurse #20 said she had prepared NS #1's medications for administration when NS #1 came to the medication window, but had opted not to administer the Lithium as NS #1 had bloodwork pending to determine if the dosing of NS #1's Lithium was appropriate to treat his/her symptoms. Nurse #20 said she placed the medication in a medicine cup, wrote NS #1's first name on the medicine cup, and then put the cup on top of the medication cart.

Nurse #20 said she had prepared NS #2's medications for administration when NS #2 came to the medication window, but said NS #2 then refused the medications. Nurse #20 said she placed the medications in a medicine cup, wrote NS #2's first name on the medicine cup, and placed the medicine cup containing the medications on top of the medication cart.

The Surveyor heard Nurse #2 asked Nurse #20 what patient the nicotine patch on top of the medication cart belonged to, and how long it had been there. Nurse #20 said she did not know what patient the nicotine patch belonged to, and said she thought the patch had been on top of the medication cart for a couple of days. Nurse #2 instructed Nurse #20 to dispose of the nicotine patch.