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Based on observation, interview, and document review, the facility failed to maintain accurate records of expired scheduled/controlled drugs (e.g. narcotics), resulting in the potential for improper use and/or abuse of these drugs for all patients served by the facility. Findings include:

Observation of the Pharmacy "Vault" (controlled medication room), on 6/21/16 at approximately 1130, revealed many scheduled/controlled drugs (e.g. narcotics) on shelves. A request to review and count expired controlled drugs revealed that these drugs were kept in drawers inside of small separate plastic bags. Pharmacist P provided a document titled, "Meds Pending Destruction Report, dated 6/21/16 11:47:50 AM." On page three of this report was listed "Total Qty of HYDROMORPHONE INJ 1 MG SYR (928268) Pending Destruction: 7." Pharmacist P looked through the expired medication drawers and was not able to find these seven (7) narcotic syringes pending destruction. Initially Pharmacist P stated, "The report had errors one other time." After further inquiry, Pharmacist P stated, "It must have been picked up already by XYZ (a disposal company)." This was not evident in the review of the disposal company paperwork on 6/21/16 at approximately 1215. Accurate disposition of these seven (7) Hydromorphone syringes could not be determined.