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Based on hospital record review, medical record review, and staff interview, the facility failed to maintain an accurate record of receipt and distribution of a scheduled medication provided to sample patient #1.

The findings were:

Medical record review was conducted on 2/17/2011, which revealed that sample patient #1 received a dose of Fentanyl 50 mcg intravenously on 2/10/2011 at approximately 11:40 p.m.

A review of the hospital's medication dispensing cabinet report for the department, sample patient #1 was treated was reviewed on 2/17/2011. The report revealed that at approximately 11:36 p.m., Fentanyl 100 mcg/2 ml ampule was removed by the nurse treating sample patient #1. No documentation existed in the report of the wasting of the remaining 50 mcg of Fentanyl (a controlled substance).

An interview with the Director of Patient Safety, Quality, and Regulatory Compliance was conducted on 2/17/2011 at approximately 1:50 p.m. and revealed that there was no documentation of the wastage of the remaining 50 mcg of Fentanyl for sample patient #1 and that it would be documented in the report provided if the documentation existed.