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Based on interview and document review, this standard was not met when the hospital failed to keep accurate record of all scheduled drugs for 2 of 10 surgical records reviewed (P1, P7). Certified registered nurse anesthetist (CRNA) staff failed to document narcotic use accurately during surgery. Although the hospital discovered the concern and initiated audits of the CRNA documentation and reported the concern, they were not aware of corrective action taken related to the issue because the CRNA staff work for a contracted company and the contracted company completed the corrective action.

Findings include:

Medical record review revealed P1 was admitted to the hospital on 8/15/19, through the emergency room for incision and drainage of his upper extremity. The Anesthesia Box Administration Sheet ( for the locked medication box) dated 8/15/19, revealed CRNA-P documented giving P1 2 cc of Fentanyl and 2 cc of Midazolam, both controlled, scheduled drugs.

During an interview on 2/19/20, at 12:30 p.m. registered nurse (RN)-I stated he worked in the Operating Room on 8/15/20, with CRNA-P for P1's surgery. After the case was finished and staff were cleaning the room, surgical tech (ST)-K brought two full syringes out of the room that he said were laying on the bed. Although the medications Fentanyl and Midazolam were charted as given, they were never given to the patient but were still in the syringes. RN-I stated he went to CRNA-P and gave him the syringes telling him they were found in the OR after the case. Later RN-I checked the pharmacy documentation to ensure that the scheduled medications were returned to the pharmacy per policy. He found out the medications were not returned. RN-I reported the concern.

During an interview on 2/19/20, at 10:50 a.m. physician (MD)-G stated the hospital was aware of a discrepancy related to the administration of the controlled medications for P1. CRNA-P, when asked, said he wasted the medications alone. The policy for controlled medications includes that the medications should be returned to pharmacy. This policy was not followed. The hospital staff were not aware of the corrective action taken by the contacted anesthesiology company (AAPA) related to the reported discrepancies.

Medical record review revealed P7 was admitted to the hospital on 10/7/19. P7 had surgery on 10/7/19, for percutaneous nephrolithotomy. The CRNA documented that 2 ml of Fentanyl and 2 ml of Midazolam were administered to the patient on the pharmacy narcotic sheet. The CRNA did not document the patient got those medications in the patient record. The medication was not returned to pharmacy.

During an interview on 2/20/20, at 10:15 a.m. clinical pharmacy manager (CPM)-D stated after the incident with CRNA-P on 8/15/19, staff began auditing the CRNA records to ensure that all scheduled medication used in surgery were documented correctly on the pharmacy documentation, as well as in the patient chart. For the previous 5 months 3,400 cases had been audited, and 15 discrepancies had been followed up on. Although a trend was identified for CRNA-P and he was suspended, there have been no other trends or suspicious events identified related to specific staff not correctly documenting use of controlled medications. CPM-D stated 100% of surgical cases have been reviewed for the last 5 months.

The facility policy Controlled Substance Security undated directed under section D. 2: All waste for controlled substances provided via lock box should be returned to pharmacy for reconciliation and wasting.