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Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to ensure that outdated drugs were not available for patient use.

Findings were:

Facility Policy for Pulling Expired Drugs and Biologicals, undated, instructed that pharmacy stock would be checked monthly for expired drugs which would be pulled from the shelves.

During a tour of the pharmacy at 3:00 p.m. on 04/17/2012 with the Lead Pharmacist (employee #8), it was observed that the following expired medications were on the shelves, and available for patient use:
-(20 bottles) Clindamycin (an antibiotic) 600 milligram (mg- unit of measure)/4 milliliter (ml- unit of volume), 4 ml bottle, expired 3/1/2012;
-(7 bags) 50% Dextrose (an intravenous [in the vein] sugar solution of 50% dextrose [type of sugar] in water) 50 ml, expired 2/1/2012;
-(10 bottles) Amidate Injection (short acting intravenous anaesthetic agent used for general anesthesia and sedation) 2 mg/ml, 20 mg, expired 4/1/2012;
-(1 bottle) Haloperidol (an antipsychotic) 2 mg tablets, expired 1/2012;
-(1 bottle) Terazosin Hydrochloride (drug used for treatment of high blood pressure and prostate enlargement) 1 mg capsules, expired 3/2012;
-(4 bottles) Sodium phosphate (salts of sodium hydroxide and phosphoric acid used intravenously to replenish electrolytes in the body) 15 ml, expired 3/1/2012;
-(11 bottles) Sodium chloride 23.4% (concentrated solution of salt water used intravenously to replenish electrolytes in the body) 30 ml, expired 3/2012;
-(2 bottles) Vancomycin Hydrochloride (an antibiotic) 500 mg, expired 4/1/2012;
-(3 bottles) Xylocaine MPF 2%, (local anesthetic administered by injection) 5 ml, expired 8/2011;
-(1 bottle) Enalapril Maleate (used for treatment of high blood pressure and some types of chronic heart failure) 10 mg tablets, expired 2/2012;
-(4, 4-packs) Sodium Chloride Injection (sterile solution of salt in water for intravenous use), 25 ml, expired 2/2012; and
-(2 bottles) Sodium phosphate (salts of sodium hydroxide and phosphoric acid used intravenously to replenish electrolytes in the body) 15 ml, marked as opened 4/17/2012, expired 3/1/2012.

At the time of discovery, the lead pharmacist confirmed the above findings and stated that although the pharmacy had been short staffed, he/she had believed that the medications had been checked for expiration dates, and expired medication removed.

Based on review of policies and procedures, observation and staff interview, it was determined that the facility failed to ensure that patient medical records were protected against loss from fire or water damage.

Findings were:

During a tour of the Medical Records Department/building, with its Director (employee #19), at 2:30 p.m. on 4/18/2012, the Director explained that the Medical Records Department had been located in a larger building, but was relocated to a smaller house that had been converted into the new Department. The tour of the building revealed stacks of boxes sitting on the floors and filling each of three rooms in the building- a kitchen, a smaller room, and a room which the Director explained had been converted from a garage/carport. The Director further explained that the Department was in the process of scanning and archiving patient records, and that the boxes the surveyor observed contained the medical records of services provided to patients prior to 2008.

Further inspection of the building revealed a smoke detector located in the kitchen. The Director confirmed that the smoke detector was not connected to the hospital alarm system and if it sounded after business hours, could not alert hospital staff or the fire department of a fire in the building. The Director also acknowledged that the medical records in the boxes on the building's floors were not protected against intrusion of water from leaks or floods.

During a subsequent interview in the conference room at 3:05 p.m. on 4/19/2012, after reviewing the Medical Record Department policies and procedures, the Medical Record Department Director confirmed that the department did not have a policy which directed staff in the storage and protection of patient medical records.