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Based on record review and interview, the facility failed to insure that procedures were followed to assure proper use of medications for 3 of 10 sampled patient records (#3, 9 & 10).

Findings:

Patients #3, #9 and #10 records reflected the patients were seen in the emergency department (ED) and had injuries which required Diphtheria/Tetanus (DT) injections. Review of the patient #3's record reflected the patient received DT at 8:42 p.m. on 11/27/09. It also reflected the DT lot #U2294CA had expired 6/07/10. However, review of facility documentation of the investigation reflected the lot had expired 6/07/09. Patients #9 and #10's records also reflected DT injections were given.

Review of the Pyxis activities log of 12/01/2009 reflected that the DT dosed administered to patients #3, #9 and #10 were expired with an expirations date of 06/07/09. The records failed to document the nursing staff recognized the medications had expired at the time they were administered. The records reflected that all patients were offered a repeat dose of DT.

Review of facility policies reflected they were consistent with current standards of care and regulations.

Interview with the ED Manager, Chief Nursing Officer (CNO), Director of Pharmacy, Vice President of Quality, Risk Manager, and Risk Analyst on 01/26/10 at 4:30 p.m. confirmed the records were accurate and that patients #3, #9 and #10 received expired medications.

Based on record review and interview, the facility failed to insure that procedures were followed to assure proper use of medications for 3 of 10 sampled patient records (#3, 9 & 10).

Findings:

Patients #3, #9 and #10 records reflected the patients were seen in the emergency department (ED) and had injuries which required Diphtheria/Tetanus (DT) injections. Review of the patient #3's record reflected the patient received DT at 8:42 p.m. on 11/27/09. It also reflected the DT lot #U2294CA had expired 6/07/10. However, review of facility documentation of the investigation reflected the lot had expired 6/07/09. Patients #9 and #10's records also reflected DT injections were given.

Review of the Pyxis activities log of 12/01/2009 reflected that the DT dosed administered to patients #3, #9 and #10 were expired with an expirations date of 06/07/09. The records failed to document the nursing staff recognized the medications had expired at the time they were administered. The records reflected that all patients were offered a repeat dose of DT.

Review of facility policies reflected they were consistent with current standards of care and regulations.

Interview with the ED Manager, Chief Nursing Officer (CNO), Director of Pharmacy, Vice President of Quality, Risk Manager, and Risk Analyst on 01/26/10 at 4:30 p.m. confirmed the records were accurate and that patients #3, #9 and #10 received expired medications.