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Based on review of medical records, staff interview and review of facility policy and procedures it was determined the facility failed to ensure medications were controlled and documented according to standards of practice for three (#3, #11, #12) of thirteen patient records sampled.

Findings included:

Review of the facility policy "Medication Management" stated the patient's electronic medication administration (eMAR) record shall be a record of medications administered and to be administered to an individual patient over a twenty-four hour period. Departments providing diagnostic or treatment services may document medication administration in eMAR.

1. Review of the medical record for patient #3 revealed the patient was admitted to the facility on 8/12/2016 for a surgical procedure. Review of the physician's operative report revealed Monsel's Solution was administered. Review of the intra-operative documentation and the eMAR revealed no documentation of the medication or the amount of the medication used.

Interviews were conducted with two RN's (Registered Nurses) on 1/10/2017 at approximately 1:30 p.m. that were present at the time of the procedure on 8/12/2016. The RNs stated 10 ml (milliliters) of the medication was drawn up in a syringe but they could not confirm the total amount used.

2. Review of the OR (Operating Room) Pyxis medication summary for Monsel's paste was reviewed. Two (#11, #12) patient's medical records reviewed. The sampled patient's had Monsel's paste removed under their name.

Review of patient #11's medical record revealed the patient was admitted to the facility on 11/18/2016 for a surgical procedure. Review of the intra-operative documentation and the patient's eMAR revealed no documentation the medication was administered. Review of the Pyxis summary revealed no evidence the medication was wasted due to non-use.

Review of patient #12's medical record revealed the patient was admitted to the facility on 10/21/2016 for a surgical procedure. Review of the intra-operative documentation and the patient's eMAR revealed no documentation the medication was administered. Review of the Pyxis summary revealed no evidence the medication was wasted due to non-use.

Interview and review of the medical records with the Vice President of Quality and the Director of Surgical Services on 1/10/2017 at approximately 3:15 p.m. confirmed the findings.