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Based on observation, interview and record review, the facility failed to:

A. ensure the immediate environment and equipment in the pharmacy was kept up in a manner to prevent cross contamination 2 of 3 critical care units (Cardiac (CICU) and Medical intensive care unit MICU).

The facility failed to ensure medications were compounded in a manner to ensure patient safety. They failed to ensure medications and equipment used during the compounding process were stored in a manner to prevent contamination.

B. ensure narcotics were stored in a manner to prevent drug diversions. Narcotics were not stored under double locks and were not returned to the Pyxis timely when not in use. The facility failed to ensure all medications were secured at all times.

Refer to tag A0500 for additional information.