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Based on observation, interview and policy review, it was determined the facility failed to secure controlled substances used in the Operating Room to sedate patients.

The findings include:

Review of the Medication Storage policy revised 8/10, revealed medications were secured according to the Centers for Medicare and Medicaid Services guidelines where all medications, including non-prescription medications are in locked containers in a room or are under constant surveillance so that unauthorized persons cannot obtain access to them. Medications, including non-controlled drugs, are secured at all times and locked when a patient care area was not staffed. Housekeeping, Material Management, and Dietary can access a room where unlocked non-controlled medications were stored.

Review of the Anesthesia Safety Activities policy revised 8/10, revealed all anesthesia carts and operating room cupboards shall be locked when not in use. All medications opened and unused are discarded at the completion of the case. All Intravenous (IV) solutions with admixtures or opened solutions shall be discarded, if unused after each case.

Observation of the Operating Room (O.R.) #1, on 02/21/12 at 8:50 AM, revealed a sterile field where medications by the name of Neosynephrine (which is known to dilate the nose canal), Ephedrine (which increases heart rate), Robinul (pre-op medication which increases heart rate), Zemuron (paralytic, helps to put patients asleep), Amidate (Anesthesia, helps put patients asleep), Succinylcholine (Anesthesia, helps put patients to sleep), Propofol (anesthesia, helps put patients to sleep), Glycopyrrolate and Labetalol Hydrochloride (for blood pressure) were kept. All of these drugs were observed in the O.R. not supervised by any licensed staff, with one Housekeeper in the room cleaning up.

Interview with Nurse Anesthetists, on 02/21/12 at 8:50 AM, revealed a patient with respiratory concerns took his attention away from the medications. The Nurse Anesthetists stated none of the drugs were missing and he should have told the circulating nurse to monitor the medications. Interview at 9:50 AM, revealed it was not a common practice to leave medications out and in normal circumstances the medications would not be left out.

Interview with the Medical Doctor of Anesthesiology, on 02/21/12 at 2:08 PM, revealed staff tried to take care of O.R. drugs and keep them under lock and key. She stated if staff were worried about an airway, the staff should try to keep the drugs with them. The Medical Doctor of Anesthesiology stated they had a drawer and if they need to they could lock the drugs in a drawer and keep them contained. She further stated no staff had complained about medications coming up missing.

Interview with the Charge Nurse of the O.R, on 02/21/12 at 1:23 PM, revealed any drug left out in the O.R. was not acceptable. She further stated she did not think it was allowed for the anesthetist to keep medications, open and unattended.