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Based on observation and interview with staff, the facility failed to have a policy in place to ensure that outdated or expired drugs and supplies are not available for patient use. Expired drugs and supplies were found in in 7 patient care areas available for patient use, which could potentially result in patients receiving medications and/or supplies that are ineffective or non-sterile.


Findings were:


A tour of the facility was conducted the afternoon of 9/29/14 in the company of the Director of Nurses (DON), Staff #1. In the MRI room, 5 lab tubes were found which had expired in 2012 and 2013. Three butterfly IV cannulas were found which had expired in 6/2014. Four IV start kits expired in 2013 and 7 were found that expired in 2014. In the Specialty Clinic, 9 packages of electrodes expired in 7/2014 and 6 needles for syringes had expired in 2012 and 2013. Two jars of culture medium expired in 5/2011, and 3 lab tubes expired in 2012 and 2013; a vial of sodium chloride expired in 8/2014. In the Procedure Room was found a package of electrodes which expired in 5/2014; 6 tegaderm bandages which expired in 1/2014; and 6 vials of sodium chloride which expired in 11/2014. The crash cart in the main nursing station area had 2 packages of electrodes which expired in 4/2014. In the ER, a vial of ear drops was found which had expired in 1/2014 and nose drops which expired in 10/2012. In the ER crash cart, a package of pediatric electrodes were found that expired in 6/2013. Also, a bottle of iodoform packing strips expired in 10/2013. In the CT room, a package of markers were found which had expired in 4/2014. In the x-ray room, 14 vials of sodium chloride were found which expired 3/2014. All items were available for patient use.


An in-person interview was conducted with the DON the afternoon of 9/29/14. Staff #1 stated that the expired supplies and biologicals were available for patient use in 7 areas of the hospital. The DON also indicated that there was not a facility policy that included specific rules to ensure that outdated or expired supplies are not available for patient use.