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Based on observation, interview, and document review, 1 of 3 outpatient clinics observed failed to ensure drugs were stored in secure areas to prevent unauthorized persons from obtaining access.

Findings include:

A tour of the Alexandria Clinic was conducted on 9/4/14, at 12:15 p.m. with director of clinical services (DCS)-A, patient flow coordinator (PFC)-B, and clinic supervisor (CS)-C. The urgent care department had a locked cupboard located in the back of the clinic, which the CS-C identified as the facility narcotic cupboard. The CS-C obtained the key which was located in an unlocked drawer next to the cupboard. The cupboard contained a small, unlocked Rubbermaid container with drawers, which contained the following:
One, 2 ml (milliliter) vial of Versed.
18, 2 ml vials of Fentanyl.
22, one ml vials of Morphine.
27, one ml vials of Tordal.

The urgent care also had a locked medication refrigerator, and the key was hanging on the side of the fridge. The fridge contained two, 1 ml vials of Ativan.

CS-C stated the narcotics were counted daily by the nurses, however, the keys were always kept next to the cupboard and fridge, and the narcotics did not contain a double lock system for security, nor was the Rubbermaid container secured.

In patient room 239 in urgent care, a cupboard which was not able to be locked, contained the following medications:
3 Epinephrine pens.
One, 30 ml vial of Epinephrine.
Two, 20 ml vial of epinephrine with Lidocaine.

CS-C stated the cupboard in patient room 239 did not contain a locking system and was not able to be locked.

During tour of the urology department, the procedure room had a cupboard which was not able to be locked and contained the following medications:
20, one ml vials of heparin.
2, 125 mg vials of Solumedrol.

CS-C stated the cupboard in the patient procedure room did not contain a locking system and was not able to be locked.

(DCS)-A stated all cupboards containing medications should be locked to prevent unauthorized access to medications. DCS-A stated the clinic was in the process of installing a new locking system for medications which required a badge to obtain access. DCS-A stated in the evening after the clinic closes at 7:00 p.m., there is maintenance and housekeeping that enters the building and has access to all clinic areas.

During interview on 9/4/14, at 1:10 p.m., pharmacist (P)-A stated the pharmacy department does audits of the outpatient clinics to ensure medications are secured and locked. P-A stated the narcotic storage was not considered secure, and the nurses should be carrying the keys with them, and not leaving them in a drawer next to the cupboard/ fridge. P-A stated he was not aware of the unlocked medications stored in the patient rooms and all medications in patient areas should be locked.

A specific policy was requested regarding securing medications in patient areas in the outpatient setting, however, the facility was unable to provide a specific policy related to outpatient medication security.

Based on interview and document review, the hospital failed to develop a plan which delineated how water was to be prioritized and distributed in the event of an emergency and or a disruption of supply. This had the potential of affecting 47 patients which represented the hospital's average daily census.

Findings include:

The facility's Emergency Preparedness Plan, revised 7/14, indicated if there was no water supply or the water supply was shut off, bottled water in the storeroom (0.5 gallons per person per day) were to be saved for cooking and drinking only. The plan did not specify the amount of non-potable water required per patient, staff, visitors and the different departments per day, nor how any of the water would be distributed.

During interview on 9/4/14, at 11:30 a.m., the director of food and nutritional services (DFNS), and director of engineering services (ES) stated the amount of bottled water needed was calculated to accommodate 100 inpatients, although the policy did not state that number. ES stated when it came to non-potable water, the staff would just come down and get buckets as needed and there were no calculations completed to determine how much non-potable water was needed. DFNS and ES stated the bottled water would be distributed per the census, however, they were unable to explain how that would be done.

During the interview, DFNS and ES agreed the current plan did not meet the requirements of the regulation.