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Based on observation, interview, and record review, the hospital failed to ensure emergency drugs in Acute Care (AC) crash cart (CC) were stored in a locked drawer. This failure had the potential for diversion by unauthorized persons and adverse events.

Findings:

During a concurrent observation and interview on 4/10/23, at 2:10 PM, in AC, with Licensed Vocational Nurse (LVN) 2, The first drawer of AC CC was unlocked. LVN 2 opened the drawer and found one tray containing the following medications:

1 Calcium Chloride (used in medical emergency to improve heart muscle contraction) 1 Gm (Gram-unit of measure)/ 10 ml (milliliter-unit of measure).

2 Sodium Bicarbonate (used in medical emergency to help the body, restore normal balance needed for the body to survive and function correctly) 50 mEg [miliequivalent, a unit of measure)/50 ml.

2 Lidocaine (used in medical emergency to treat and improve abnormal heart rhythm) 100 mg (milligram-unit of measure)/5 ml.

5 Adenocard (used in medical emergency to help restore normal heartbeats in people with certain heart rhythm disorders) 6 mg/2 ml.

3 NaCl (Sodium Chloride-Control fluids distribution) 0.9 % (percent) 30 ml vial (For Adenocard).

6 NaCl 0.9 % 10 ml syringe.

1 Metoprolol (medication to lower Blood Pressure and Heart Rate) 5mg/5 ml.

1 Naloxone (Narcan-Indicated for emergency treatment of known or unknown drug overdose) 4 mg Nasal.

2 Naloxone 2 mg/2 ml

LVN 2 stated, "The first drawer contains all the emergency medications. I don't know why it's unlocked. It's supposed to be locked." LVN 2 added, "The pharmacist should know it's unlocked."

During a concurrent observation and interview on 4/10/23, at 4:11 PM in AC, with Hospital Pharmacist (HP), HP opened the AC CC and acknowledged the drug drawer was unlocked and unsecured. HP stated, "Yes crash cart drug drawer must be locked using a red seal (lock use to secure the crasch cart medication drawer)."

During a review of the hospital's policy and procedure (P&P) titled, "CRASH CART CHECKS" dated 4/6/11, indicated, "B. Crash Cart seal usage: 1. Red seals are restricted to use by Pharmacists only and are used to seal the medication drawer. . . 2. Crash cart checks include. . . f. All drawers are sealed, dated, and initialed."