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Based on interview and record review, the facility failed to follow their policy on:
1. Limiting the number of keys to the Drug Room, causing less secured medication storage.
2. Limiting the number of keys to the controlled substance (medications subject to abuse) vault in the Drug Room. This failure created additional staff authorized to access the vault which could potentially cause tracking difficulty in case of loss and/or diversion.

Findings:

During an interview with the CNO (Chief Nursing Officer), on August 6, 2010 at 10:55 AM, he stated the facility had eight keys to the Drug Room. He stated the Drug Room keys were distributed as follows: two in the Emergency Department, one kept by the Pharmacist, one to the Medical/Surgical Unit, one to the Assistant Director of Nurses, one to the shift supervisor, one to the QA (Quality Assurance) Nurse, and one kept by him.

The facility had two policies each indicating a variation of the number of keys to the Drug Room:

---One policy was entitled, Drug Room Key Control, effective January 28, 1997; reviewed and revised March 20, 2000. It read in part ..."POLICY: Possession of the Drug Room keys will be strictly limited to insure safety to the patients and the staff at (name of facility). PROCEDURE: Keys to the Drug Room shall be distributed to the following persons: Front Door: 1. Charge Nurse and Emergency Room Nurse 2. Clinical Director of Patient Care Services 3. Consultant Pharmacist 4. Assistant Director of Nurses 5. Physicians." The policy did not quantify the total number of keys to the Drug Room. There was no mention of how many physicians had key(s).

---Another policy was entitled, Access to Drug Room, effective January 28, 1997, reviewed and revised March 21, 2000. It indicated the staff authorized to carry the key to the Drug Room were as follows: Charge Nurse, Clinical Director of Patient Care Services, Consultant Pharmacist, and Assistant Director of Nurses.

During this same interview with the CNO, he stated the facility had four keys to the controlled substance vault in the Drug Room. He stated the pharmacist, the Assistant Director of Nurses, the QA Nurse, and himself had one key apiece.

The same Drug Room Key Control policy indicated the keys to the controlled substance vault in the Drug Room shall be distributed to the following three personnel: Clinical Director of Patient Care Services, Consultant Pharmacist, and the Assistant Director of Nurses. This policy made no mention of a key to the controlled substance vault for the QA Nurse.

Based on interview and record review, the facility failed to perform annual reviews of their policies resulting in outdated policies and of potentially leaving policies in place that were no longer current standards of practice.

Findings:

During an interview with the Consultant Pharmacist, on August 6, 2010 at 12:30 PM, she provided the following policies:
1. Drug Room Key Control, effective January 28, 1997; reviewed and revised March 20, 2000.
2. Access to Drug Room, effective January 28, 1997; reviewed and revised March 21, 2000.
3. Drug Room Policies, effective January 28, 1997; reviewed and revised March 21, 2000.
4. Access to Medication Room, effective March 31, 2000; reviewed May 21, 2000; revised May 23, 2000.
5. Procurement of Pharmaceuticals (Acute Care - General Medications and Controlled Substances), effective March 7, 1993; reviewed May 14, 2000; revised May 23, 2000.
6. Drug Ordering, Receiving, Dispensing, and Record Keeping, effective April 8, 1983; reviewed and revised June 25, 2000.
7. Administration of Medications, effective January 24, 2000; reviewed and revised January 24, 2000.
8. Medication Administration Personnel, effective April 6, 1993; reviewed May 13, 2000; revised May 23, 2000.
9. Disposal of Outdated or Discontinued Medications, effective June 4, 1993; reviewed and revised November 25, 2003.
10. Destruction of Medications, effective June 4, 1993; reviewed May 27, 2003; revised May 27, 2003.
11. Controlled Substance Loss Policy, effective, reviewed, and revised November 21, 1999.

The Consultant Pharmacist stated they were in the process of reviewing the pharmacy policies and would be developing the necessary revision(s).