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Based upon policy and procedure reviews, observational tours and staff interviews, the hospital staff failed to discard 1 of 1 multiple dose vial medication for 1 of 4 units toured (2A) and failed to remove unusable and outdated medication from patient care areas for 2 of 4 units toured (2A and Mother Baby).

The findings include:

Review of hospital policy, "Guidelines for the use of Multiple Dose Vials" with a review date of 11/10 revealed, "POLICY: ...Once opened, a multiple dose vials may be used until the date recommended by the manufacturer or for twenty-eight (28) days (four (4) weeks), which ever comes first. ...PROCEDURE: ...II. Multiple use vial...B. An expiration date or discard date will be indicated on opened multiple dose vials. Open vials found without expiration / opening date will be discarded immediately. ..."

Review of hospital policy, "Outdated/Deteriorated Medication Control/Deposition" with a review dated of 03/12 revealed, "PURPOSE: ...POLICY: All unusable, deteriorated, or outdated medication will be immediately removed from all areas of the hospital and will be returned to the pharmacy for proper deposition. ..."

1. Observational tour conducted 02/03/2015 at 1150 of 2A-patient care unit revealed nurse #1 removed 1 of 1 opened Novolog-multidose insulin vial (blood sugar medication) in the automated medication dispensing unit for patient medication administration. Observation revealed nurse #1 failed to inspect the multidose insulin vial for an open date or a discard date prior to withdrawing insulin from the multidose insulin vial. Observation of the multidose insulin vial revealed no open date nor a discard date was marked on the multidose insulin vial.

Interview conducted 02/03/2015 at 1150 with Administrative Staff #1 and nurse #1 revealed the multidose insulin vial had no open date nor a discard date was marked on the multidose insulin vial. Interview revealed the mulidose insulin vial should have been discarded.

Interview conducted 02/04/2015 at 1500 with the Pharmacy Director revealed monitoring of medication discard date was a team approach; however, the pharmacy department was primarily responsible because the insulin vials were dispensed from pharmacy with a discard sticker on the insulin vial which was automatically 28-days. Interview revealed the mulidose insulin vial should have been discarded because no open date was wrote on the vial nor

2. Observational tour of the Mother Baby unit conducted 02/03/2015 at 1000 revealed 2 of 2 Hydromorphone (pain medication) syringe located in the refrigerator which was access via the automated medication dispensing unit. Observation revealed 1 of 2 Hyrdomorphone syringes had an expiration date of 01/2015(30 days expired).

Interview conducted 02/03/2015 at 1000 with Administrative Staff #1 revealed 1 of 2 Hydromorphone syringes had an expiration date of 01/2015 (30 days expired). Interview revealed the expired syringe should have went back to pharmacy for disposal.

Interview conducted 02/24/2015 at 1500 with the Pharmacy Director revealed monitoring of medication discard date was a team approach; however, pharmacy was primarily responsible because pharmacy placed the Hydromorphone syringe into the automated medication dispensing unit with the earliest expiration date to be dispensed first. Interview revealed the expired syringe should have went back to pharmacy for disposal.

3. Observational tour of 2A-patient care unit conducted 02/03/2015 at 1150 revealed patient medication bin for room 241. Observation revealed three (3) pills (1 pill-white; 1 pill-orange; 1 pill-pink) were located inside a biohazard bag. Observation revealed the three pills were not in their original packaging; which would have made the pills unidentifiable. Observation revealed the three pills were unidentifiable.

Interview conducted 02/03/2015 at 1150 with Administrative Staff #1 revealed the three pills were located inside a biohazard bag and were not in their original packaging. Interview revealed the three pills were unidentifiable and therefore unusable.

Based upon hospital policy reviews, observations during tours and staff interviews, the hospital staff failed to discard expired products from patient care areas for 3 of 4 units toured (Mother Baby, Special Care Nursery and 2C).

The findings include:

Review of hospital policy, "Nova Biomedical StatStrip Glucose Meter" with a review date of 07/2014 revealed, "PURPOSE: ...SCOPE: ...EQUIPMENT AND MATERIALS: ...Performance Parameters: Storage Requirements: 1. ...Write the opened date on the test strip bottle when your first open it. Discard any unused test strips 6 months/180 days after first opening the bottle. ...2. ...Date on the vial upon opening. Do not use solutions after the expiration date printed on the vial label, discard any unused portion 3 months/90 days after opening. ..."

Review of hospital policy, "Stock Rotation and Expiration Dated Supplies" with a date of June 2002 revealed, "PURPOSE: ...POLICY: ...PROCEDURE: 1. ...2. Material Management staff will check monthly all items that have expiration dates, in their areas of responsibility. ...3. Dated supplies that will expire within 90 days will be tagged and pulled to the front of the shelf. Dated supplies that will expire in 30 days or have reached their expiration date will be pulled. ..."

1. Observational tour of the Mother Baby unit conducted 02/03/2015 at 1000 revealed 2 of 2 Glucose Meter strips were used for patient care. Observation revealed the 2 of 2 Glucose Meter strips had no open date.

Interview conducted 02/03/2015 at 1000 with the Mother Baby Administrative staff revealed 2 of 2 Glucose Meter strips had no open date and should have been discarded.

Interview conducted 02/04/2015 at 1510 with the Clinical Laboratory Supervisor revealed the staff member that opens the Glucose Meter strips, writes the open date. Interview revealed the Glucose Meter strips last up to six (6) months. Interview revealed this was policy based which was provided upon hire and annually. Interview revealed the strips should have been discarded.

2. Observational tour of the Special Care Nursery conducted 02/03/2015 at 1110 revealed eight (8) boxes of ready-to-feed nourishments. Observation revealed each box had six (6) bottles with (2) fluid ounces per bottle. Observation revealed the eight boxes of ready-to-feed nourishments expired 01/2014.

Interview conducted 02/03/2015 at 1110 with Administrative Staff #1 and the charge nurse of the Special Care Nursery revealed the eight boxes of ready-to-feed nourishments expired 01/2014 and should have been pulled from the patient care area.

Interview conducted 02/04/2015 at 1520 with the Assistant Director of Supply Chain revealed inventory was stocked as FIFO (First In First Out) and random audits were performed. Interview revealed the ready-to-feed nourishments should have been pulled from the patient care area.

3. Observation tour of 2C - patient care unit conducted 02/03/2015 at 1115 revealed 1 of 2 Glucose Meter low control solution expired 01/2015; four (4) D5 -50 ml (intravenous solution-milliliter) expired 08/2014; one (1) D5-50 ml expired 11/2014 and one D5.45NS-500 ml expired 10/2014.

Interview conducted 02/03/2015 at 1115 with the Unit Manager of 2C revealed the low control solution and the three (3) intravenous solution were expired and should have been pulled from the patient care areas.

Interview conducted 02/04/2015 at 1510 with the Clinical Laboratory Supervisor revealed the staff member that opens the Glucose Meter solution, writes the open date. Interview revealed this was policy based which is provided upon hire and annually. Interview revealed the Glucose Control solution should have been discarded.

Interview conducted 02/04/2015 at 1520 with the Assistant Director of Supply Chain revealed inventory was stocked as FIFO (First In First Out) and random audits were performed. Interview revealed the intravenous solution bags should have been pulled from the patient care area.

NC00102496