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Based on interviews and record reviews the facility failed to develop policies and procedures that minimize drug diversions and errors. The facility failed to ensure drugs listed in schedules II, III, and V of the Comprehensive Drug Abuse Prevention and Control Act were accounted for by licensed nursing staff daily, between shifts.

Findings include:

In an interview conducted on 9/24/18 at 1:00 pm, the nurse manager on the medical surgical floor revealed that nursing staffs were only conducting controlled medication counts (with 2 licensed persons) on a weekly basis.

In an interview conducted on 9/25/18 at 11:30 am, the director of Pharmacy confirmed the above findings.


Record review of the facility policy entitled: Controlled Substances, dated 02/01/2012 revealed in part the following information:

Security of Controlled Substances:
-Current and and accurate records are maintained on the receipt and disposition of all scheduled drugs.

-Pyxis Inventory:
- Inventory counts will be performed on all controlled substances on Friday of each week by two Registered Nurses.

Based on observation, interview and hospital policy review, the hospital failed to meet the requirement to implement and enforce its own policy on packaging of instruments for sterilization because instruments were packaged without a description of the item and/or without the initials of the staff member that packaged them.

Findings Included:

During a tour of the sterile instrument room on 09/24/18 at 2:30 p.m. accompanied by the Sterile Processing Supervisor, observation revealed the following instruments were available for patient use:

Wrapped items and items in peel pouches without a description of the item or the initials of the staff member that packaged them.

Hard sided trays identified by the Sterile Processing Supervisor as "rep trays" without the initials of the staff member that packaged them.

In an interview on 09/24/18 at 2:30 p.m. in the instrument room, the Sterile Processing Supervisor confirmed the above findings and confirmed that the staff were not labeling wrapped items, peel pouches and "rep trays" with the initials of the staff member that packaged them and were not labeling wrapped items and peel pouches with a description of the item.

The facility policy entitled, "Selection and Use of Packaging Materials" and "approved 05/22/2018," was reviewed on 09/24/18 at 3:00 p.m. in a conference room and stated the following in part:

"Packages are labeled according to established facility policies and procedures. Labeling includes but is not necessarily limited to the following:
A description of package contents
Initials of the person preparing the package"