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FRANKLIN COUNTY MEMORIAL HOSPITAL
PATIENT CARE POLICIES
Tag No.: C1016
Based on observation, staff interview, and policy and procedure review, the facility failed to ensure their medication policies regarding recognizing and monitoring outdated drugs was followed to ensure that expired drugs were not available for patient use in two (2) out of five (5) areas surveyed: Swing Bed Drug Room and Oral Surgery Room
Findings Include:
Observation on 06/20/2023 at 11:20 a.m., during a tour of the Swing Bed drug room with the Director of Nursing (DON), Infection Control (IC) Nurse, and the Swing Bed Charge Nurse, the following expired medications were found in a locked drawer:
Two (2) 500 milliliter bags of Dextrose 5 percent (%), expired September 2022
Three (3) 100 milliliter bags of Dextrose 5%, expired February 2023
One (1) 1000 milliliter bag of Dextrose 5%, expired May 2023
Two (2) 250 milliliter bags of Dextrose 5%, expired April 2023
On 06/20/2023 at 11:20 a.m., expired medications found in the Swing Bed drug room were confirmed by the Director of Nursing (DON), Infection Control Nurse, and Swing Bed Charge Nurse.
Observation on 06/20/2023 at 1:22 p.m. during a tour of the Oral Surgery room with the Director of Nursing (DON) and Infection Control Nurse, the following expired medication was found on the oral surgeon's medication cart:
16 vials of Marcaine 0.5% 5 milligrams/milliliter, expired April 2023
On 06/20/2023 at 1:22 p.m., expired medications were confirmed by the Director of Nursing (DON) and the Infection Control Nurse.
Interview with Swing Bed Charge Nurse on 06/20/2023 at 11:25 a.m., revealed she does not know what this locked drawer is used for or why there were expired medications in it.
Interview with Director of Nursing (DON) and Infection Control Nurse on 06/20/2023 at 1:30 p.m. confirmed that pharmacy is responsible for checking medication expiration dates.
Interview with Pharmacist on 06/21/2023 at 1:10 p.m. confirmed he and the Pharmacy Technician are responsible to make sure expired medications are not available for use.
Review of the Facility's Pharmacy policy, "Function: Medication Management- Storage," dated 11/06/2017 revealed " ...The Director of Pharmacy or qualified designee shall conduct routing (preferably monthly) inspections of all medication areas (e.g., nursing care units, emergency medication containers, and other areas where medications are dispensed, administered, or stored) ...outdated or otherwise unusable medications are identified, removed from stock, and stored to prevent their distribution and administration ..."
During exit conference on 06/22/2023 at 12:45 p.m., findings were discussed with Quality Risk Manager, Administrative Assistant, Director of Clinical Operations, Director of Nursing, and the Administrator, no further documentation was submitted for review.