The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on facility policy, document review, observation and interview, the hospital failed to ensure all drugs were stored to prevent access by unauthorized individuals for 1 of 1 (nurses' medication storage area) medication storage areas observed.

The findings included:

1. Review of the facility's "Security" policy revealed, "...3. The following will be kept locked at all times...Pharmacy storage areas...Central pharmacy areas...Narcotic storage areas...4. When controlled substances are stored on nursing units, they should be kept securely locked and only authorized personnel should have access to these drugs. Securely locked means double lock access..."

Review of the facility's "Medication Security" policy revealed, "...All drugs stored in this Hospital shall be accessible only to authorized personnel...All drugs, except those intended for crash cart use, will be stored in lockable containers or areas...Controlled drugs will be double locked at all times prior to use...All medications at nursing stations shall be in lockable storage at all tines. Medications are stored wither in locked medication carts or in the locked cabinets or drawers in the nursing medication rooms or intravenous prep room. Authorized personnel include registered nurses, licensed practical nurses, pharmacist, pharmacy technicians and pharmacy interns..."

2. Observations of the nursing floor medication room on 7/15/19 at 5:10 PM which is located in a room that is attached to the pharmacy. Observations revealed EVS #1 used the key pad lock code and accessed the nursing floor medication room. Observations revealed an unlocked refrigerator containing medications that require refrigeration.

In an interview on 7/15/19 at 4:55 PM, in the CEO office, the CEO stated Environmental Services and Maintenance have access to the rooms where medication was stored.

In an interview on 7/15/19 at 5:00 PM, in the CEO office, EVS #1 stated she does use they key pad entry code and have access to the medication storage areas to clean them.

3. Review of a medication list, provided by the DON, revealed the following medications were stored in the nursing floor medication room refrigerator:
Insulins, Xalant eye drops, IV Pepcid, Banana bag additives (vitamins/folic acid), IV Cardizem, Bicillin and Mag Citrate.
The medications were not secured under lock and only accessible by authorized personnel.

The following controlled medications were stored in a locked box and anchored to the shelf of the refrigerator:
Intravenous (IV) Ativan, Suppository (Phenergan, Compazine, Glycerin) Amidate, Succincholine, Norcuron and Versed.
The medications were not secured under two locks and only accessible by authorized personnel.