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Based on observations, interviews, and review of CAH policies, it was determined the CAH failed to ensure Schedule II and IV (controlled medications) and other medications, were locked within a secure area and accounted for in 1 of 2 departments (Medical Surgical Unit) observed. Failure to ensure that medications were locked, secure and accounted for had the potential to increase the risk of diversion of medications. Findings include:

During an observation of the Medical Surgical Unit, on 7/27/10 beginning at 10:30 AM, it was noted that routine medications, such as suppositories, insulin, and Ativan (a controlled Schedule 4 medication), were stored in a refrigerator at the back of the nursing station. The refrigerator could not be locked and there was no log to account for and track the Ativan. In a locked cupboard that nursing staff had access to near the refrigerator, the following controlled medications were observed:

- One - 4 ounce bottle of promethazine with codeine (a controlled Schedule II medication).

- One - 4 ounce bottle of Tylenol with codeine (a controlled Schedule II medication).

- Seven individual doses of Valium (a controlled Schedule IV medication).

- Multiple individual doses of Versed (a controlled Schedule IV medication).

The CAH's Pharmacist was interviewed on 7/27/10 starting at 11:15 AM. He stated the promethazine with codeine and the bottle of Tylenol with codeine should be stored under double lock. He also stated that all the medications should have a Narcotic Disposition log where 2 nurses count the medications and verify the medication count as correct at the end of each shift.

CAH policies were reviewed. The CAH did not have a policy to guide staff with the storage and accountability of medications. This was confirmed by the CAH's Pharmacist on 7/27/10 at 11:15 AM and the CAH's DNS on 7/27/10 at 11:45 AM. The lack of a drug storage policy resulted in the CAH's inability to direct staff on where and how to store and account for medications.

The CAH failed to ensure Schedule II and IV controlled medications were locked within a secure area and accounted for.