HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure the security of all medications was maintained by leaving an unattended pharmacy with an unlocked door in one of one pharmacies. Findings include:

1. Observation and interview on 10/28/15 from 7:10 a.m. until 8:40 a.m. with the registered pharmacist revealed:
*The pharmacist was at the facility Monday through Friday every morning to restock medications or do whatever needed to have been done by the pharmacist.
*The facility used the Omnicell (automated medication delivery system) for medication administration.
*The pharmacy contained hundreds of different medications.
*The narcotics were held in a locked cabinet that only the pharmacist had access to.
*Numerous medications were stored in unlocked cupboards or containers in the pharmacy.
*In the corner next to the sink was a tray with medications that were nearing their expiration date.
*On the floor were three boxes that contained miscellaneous non-narcotic medications.
*Inside the door of the entrance into the pharmacy was a garbage-type container with a hole in the top of it.
-The container held non-narcotic medications that had been wasted or disposed of for various reasons.
-Those medications were to be destroyed.
-A person's arm could have easily reached into that container.

Observation on 10/28/15 at 7:30 a.m. revealed the pharmacist left the pharmacy to show the surveyor the Omnicell system located around the corner and down the hall approximately fifteen feet. The pharmacy could not be observed from this location. She left the door to the pharmacy unlocked. It was pointed out to the pharmacist at that time the pharmacy had been left opened and unlocked. She agreed and returned to close the pharmacy door.

Observation on 10/28/15 at 8:45 a.m. revealed:
*The door to the pharmacy was wide open.
*The pharmacist was not in the pharmacy, and was not in view of the pharmacy.
*All medications in the unlocked cupboards or containers were accessible to anyone who entered the pharmacy.
*At 8:47 a.m. the pharmacist came up the hall and returned to the pharmacy.
Interview at that time about the above incident revealed the pharmacist agreed the door to the pharmacy should not have been left open and unattended.

Review of the provider's 7/1/08 Pharmacy use policy revealed:
*"All drugs and biologicals must be kept in a locked room or container. If the container is mobile or readily portable, when not in use, it must be stored in a locked room, monitored location, or secured location that will ensure the security of the drugs or biologicals.
*All drugs and biologicals must be stored in a manner to prevent access by unauthorized individuals. Persons without legal access to drugs and biologicals cannot have unmonitored access to drugs or biologicals.
*Persons without legal access to drugs or biologicals cannot have keys to medication storage rooms, carts, cabinets or containers, Whenever persons without legal access to the drugs or biologicals have unmonitored access to or could gain access to the drugs or biologicals stored in an area, the hospital would not be considered as in compliance with the requirement to store all drugs and biologicals in a locked storage area."

Review of the provider's clinical pharmacist job description/performance evaluation revealed a Procedure Standard included: "Adheres to policies/procedures in the interdepartmental and departmental policy and procedure manuals."

Interview on 10/28/15 at 4:00 p.m. with the administrator revealed the pharmacist should not ever have left the pharmacy unattended with the door open.