HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure only authorized personnel had access to medications stored in two of two carts (anesthesia cart and medication cart) in one of one procedure room. Findings include:

1. Observation and interview on 8/28/24 at 9:00 a.m. with material purchasing technician B in the procedure room revealed:
*The procedure room was open due to another surveyor completing survey tasks.
*The material purchasing technician was asked if the red tool chest was used for medication storage.
*She then opened the unlocked anesthesia cart drawer and removed a set of keys stored in a plastic cup.
*She then opened the red tool chest (medication cart) located next to the anesthesia machine.
*The certified nurse anesthetist stored the medication cart key in the anesthesia machine drawer.
*Certified nursing assistants, housekeeping, and maintenance had access to the procedure room.
*She was not aware she or the above listed staff should not have access to medications.
*The procedure room door was secured with a punch key lock which was the normal practice.

Observation on 8/28/24 at 9:00 a.m. in the procedure room confirmed:
*In the anesthesia cart was one bottle of sevoflurane (a volatile anesthetic that provides hypnosis, amnesia, and analgesia during surgical procedures).
*The medication cart had the following medications inside of it:
-Xylocaine 20 milliliter (ml) one vial.
-Normal saline 0.9 percent (%) six syringe flushes.
-Nitroglycerin 0.4 milligrams (mg) tabs one vial.
-Ondansetron 4 mg/2 ml one vial.
-Glycopyrrolate 0.2 mg/ml two vials.
-Ketorolac tromethamine 30 mg/ml one vial.
-Naloxone 0.4 mg/ml one vial.
-Ephedrine sulfate 50 mg/ml one ampule.
-Diphenhydramine 50 mg/ml one vial.
-Lidocaine 50 mg/5 ml one vial.
-Hydralazine 20 ml one vial.
-Phenylephrine 10 mg/1 ml two vials.
-Labetalol 100 mg/20 ml one vial.
-Adrenalin 1 mg/ml one vial.
-Epinephrine 1 mg/ml one vial.
-Flumazenil 0.5 mg/5 ml one vial.
-Bupivacaine 0.25% 10 ml one vial.

Interview on 8/28/24 at 9:15 a.m. with director of nursing (DON) A and pharmacist C confirmed:
*The keys to the medication cart should not have been stored in the unlocked anesthesia cart.
*Medications stored in the procedure room would have been accessible to unauthorized personnel and should have been securely stored.
*The DON and pharmacist C were not aware the anesthetist had his own set of keys.
*A secure place to store the anesthesia medication keys would need to be determined.

Interview and review on 8/29/24 at 12:16 p.m. with pharmacy manager D of the provider's November 2023 Medications Located Outside the Pharmacy policy confirmed:
*All areas where medications were stored should have been locked at all times.
*The policy had not addressed that medications should not have been assessable to unauthorized individuals.
*She was not aware the anesthesia provider had a set of keys.
*The keys to the medication cart should not have been stored in the unlocked anesthesia cart for safety reasons.
*Medications stored in the procedure room carts would have been accessible to unauthorized staff (certified nursing assistants, housekeeping, and maintenance).