HospitalInspections.org

Based on observation, policy review and staff interview it was determined the Director of Employee Health failed to follow policy on maintaining a temperature log and monitoring for expired medication in the medication refrigerator used to store employee vaccinations. This failure creates the potential to cause harm to any employee vaccinated by the employee health nurse.

Findings include:

1. Observation on 10/6/15 at 2:00 p.m. revealed the employee health medication refrigerator has not been monitored for daily temperature checks since 3/22/15. The refrigerator contained one (1) bottle of each: influenza A vaccine, tuberculin vaccine and measles, mumps and Rubella (MMR) vaccine. The refrigerator also contained a vaccination of MMR that expired on 7/12/15.

2. Review of the policy titled, "Refrigerator Temperature Checks", last reviewed 8/11, states, in part: "All refrigerator temperatures must be checked and recorded on the Temperature Chart daily...each department shall check all medication refrigerators in their areas and keep the log daily."

3. An interview was with Pharmacist #1 on 10/7/15 at 10:30 a.m. revealed the expectation for checking expired medication in the employee health vaccine refrigerator is the responsibility of the Director of Employee Health.

4. An interview was conducted with the Director of Risk Management on 10/6/15 at 2:10 p.m. and she concurred with the above findings.