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Based on hospital policy review, observations, and staff interviews, the nursing staff failed to maintain the facility in a manner to ensure an acceptable level of safety and quality by failing to have expiration dates or legible hand written dates on glucometer control bottles for 6 out of 6 bottles and failing to ensure 2 of 12 expired culture swabs were not available for patient use.

The findings include:

1. Review of hospital policy "Accucheck Inform II" dated 01/24/2013 revealed "......Whenever an operator opens a new vial of controls, the operator must document the open date, the new 3 month expiration date, and his/her initials on the vial. The expiration date will be either 3 months from opening or the date printed on the vial label, whichever comes first."

Observation on 03/11/2015 at 1210 on patient care floor revealed 3 glucometers (Accucheck Inform II) with 2 bottles of control solutions each, totaling 6 control solution bottles: Four bottles with no dates on control solution bottles and two bottles with illegible handwritten dates.

Interview with AS #1 on 03/11/2015 at 1210 revealed "Four of the bottles don't have dates. Two of them have dates but they aren't legible."
Interview with RN #1 on 03/12/2015 at 1030 revealed controls are run on every glucometer at night by staff. "If the controls aren't run, the machine will not work."

2. Review of the hospital policy "Materials Resource Management: Stock Rotation/Expired Product" with revision date of October 2014 revealed ".....If the product is expired or expiring, the storeroom lead will alert the (Named distribution center) to arrange for new product to be shipped in immediately or prior to the expiration date of the product."

Observation on patient care floor on 03/10/2015 at 1045 revealed 2 culture swabs found in a clean utility room were expired on 1/2015 and 2/2015.

Interview with AS #1 on 03/10/2015 at 1045 revealed expired culture swabs were available for patient care use.

Interview with MPD #1 (Material Process Distribution) on 03/12/2015 at 1155 revealed MPD does not restock culture swabs for this patient care floor.

Interview with AS #1 on 03/12/2015 at 1305 revealed culture swabs are ordered by the secretary on the unit by request of nurses. "No one was checking or verifying dates. New product was being added to the bins."

NC00103235