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ROCK SPRINGS 700 SOUTHEAST INNER LOOP GEORGETOWN, TX 78626 March 21, 2018
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on review of documents and interviews with hospital staff, the facility failed to follow policy and procedures regarding patient personal medication. There was no documentation that patient's home medications which included a controlled medication were counted and returned to the patient.

Findings were:

Facility Policy entitled "Administration of Own/Personal Medication" states in part,
1. Any patient's own/personal medications that are brought into the Hospital will be counted and logged using the Home Medication Count Sheet. The patient will also sign this sheet indicating their agreement of what medications are being logged and the total number of tablets for each medication. These medications will be stored in a secure bag, and locked in the medication room. Once the patient is discharged , the medications will be pulled from the locked storage in the medication room, and the sealed bag will be opened in the presence of the patient and recounted to ensure the count is as it was when the patient arrived. Should there be a discrepancy, this will be resolved? In the event the patient was using home medications per the below steps, the discrepancy will be accounted for as routine."

Document entitled "U.S. Department of Justice-Drug Enforcement Administration- Diversion Control Division"
Schedule IV Controlled Substances
Substances in this schedule have a low potential for abuse relative to substances in Schedule III.
Examples of Schedule IV substances include: alprazolam (Xanax), carisoprodol (Soma), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).

Document entitled, "Home Medication Belongings Sheet," form revealed the patient brought the following medications from home to Rock Springs.
Lorazepam 0.5 mg - count at admission 28.
Ibuprofen 200 mg - count at admission 94.
Misc. pills in orange box - count at admission 9.
The facility document was sign by the patient and by the facility RN on 1/8/18 at 1500 when the patient was admitted to the hospital.
At the time of the patient's discharge from Rock Springs, the facility failed to document that the patient's home medications were counted and returned to the patient as per facility policy and procedures. The Home Medication Belongings Sheet was not signed by the nurse or initialed by the patient at the time of his discharge.
Documentation on the incident report stated personal belonging and medications were given to the patient.

The findings were confirmed by the Risk Manager and the Director of Nursing on the afternoon of 3/21/18.