HospitalInspections.org

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure outdated drugs were not available for patient use on one of seven nursing units (Hilltop West Unit 4).

Findings include;

Review on November 18, 2015, at 11:55 AM, of the facility policy "Pharmacy Services," last reviewed June 24, 2015, revealed "Policy Statement: Clarks Summit Hospital provides in-house Pharmacy Services, as directed by the Medical Staff and Chief Pharmacist. The Chief Pharmacist is responsible for developing, supervising and coordinating all aspects of pharmaceutical service. Purpose To meet the pharmaceutical care needs of patients maximizing patient therapeutic outcomes and minimizing medication errors via safe procurement, storage, dispensing, distribution, administration and documentation of medications in accordance with applicable federal, state and local laws and regulations. ... Procedure: ... Ward and Pharmacy Area inspections are performed monthly. ... 7. All stored medications and the components used in their preparation are labeled with the contents, expiration date, and any applicable warnings. 8. All expired, damaged, recalled and contaminated medications are segregated until they are removed from the hospital. These medications shall be removed from the active dispensing areas and stored in a container marked Expired Medications / Do Not Use. Notifications of drug recall by drug information sources or drug wholesale vendor notification system will be reviewed upon receipt. ... "

Observation on November 18, 2015, at 11:40 AM, on Hilltop West Unit 4, revealed the medication refrigerator contained Ativan 2 mg /1 ml vials. The expiration date was November 1, 2015, on seven of seven vials.

Interview on November 18, 2015, at 11:40 AM, with EMP9 and EMP10, confirmed the medication refrigerator on Hilltop West Unit 4, contained Ativan 2 mg /1 ml vials with the expiration date of November 1, 2015, on seven of seven vials. Further interview with EMP10 confirmed the medication refrigerator was inspected monthly by the nursing staff and the pharmacy, and an inspection sheet was filled out. Continued interview with EMP10 confirmed the October 2015 inspection sheet was completed October 1, 2015, with no documentation noted of a medication expiring soon, and the November inspection was not been completed as of November 18, 2015.

Interview on November 18, 2015, at 11:55 AM, with EMP11, confirmed the medication refrigerator on Hilltop West Unit 4, contained Ativan 2 mg /1 ml vials with the expiration date of November 1, 2015, on seven of seven vials. EMP11 confirmed the medication refrigerator was inspected monthly by the nursing staff and the pharmacy, and an inspection sheet was filled out. EMP11 confirmed the October 2015 inspection sheet was completed October 1, 2015, with no documentation noted of a medications expiring soon, and the November inspection sheet was not been completed as November 18, 2015. EMP11 also revealed when the medication refrigerator inspection was being completed and an expiration date that was close to expiration (usually with a month or two), the medication was replaced at that time.