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Based on record review and interview, the facility failed to provide a written plan of administrative authority for all nursing services and the duties of each category of nursing personnel was delineated.

Findings included:

Record review of facility policy titled "Staffing Policy, dated 11/3/2022, showed"

*The Administrator /DON or designee will be in charge and responsible for patient care activities.

During an interview on 1/25/2023 at 1:00 PM with Staff-J, MD, he stated the facility had a "Lead RN-Staff C-not a named "DON". He acknowledged the facility staffing policy did not clearly define a single RN with administrative authority for all nursing services. There was no documentation that showed the responsibilities of each nursing service category: lead nurse, staff RN, and ER Tech

Based on Observation, record review and interview the facility failed to ensure:
A. theft of controlled substances was reported to state agency as required
B. controlled substance waste was documented per facility policy
C. pharmacy access log was current

Findings include:

A. Record review of facility pharmacy services Quality Assurance and Monthly Audit for the month of January 2022 showed a variance of medication administration records agree with controlled substance inventory. Attached was DEA form 106 "Report of Theft or Loss of Controlled Substances" Indicating that Hydromorphone 2MG/mL vials x 10 were stolen and 6 additional vials were tampered with.

Record review of Texas administrative Code, Title 23 Chapter 131, RULE §131.61 showed the following information:

(a) A facility shall report the following incidents to the department:
(c) A facility shall report any abuse, theft, or diversion of controlled drugs in accordance with applicable federal and state laws, and shall report the incident to the chief executive officer of the facility.

Interview with facility pharmacist (ID M) on 1/25/2023 at 11:20 AM, she stated that she filled out the required DEA documentation but did not report the incident to the state agency.

B. Record review of facility policy titled " Controlled Substance Documentation of Wastage," dated 2/10/2022 showed the following information:

2. The physician on duty must witness and co-sign for all wastage and destruction at the time of the waste.

Record review of facility controlled substance log showed multiple entries with 2 record review of facility nurse signatures, not nurse and physician.

Record review of facility pharmacy services Quality Assurance and Monthly Audit form comments showed the following :
10/9/2022- Verify MSO4 (morphine) waste 10/2/22
9/11/2022- Need Hydromorphone waste witness 9/8/22
9/4/2022- 8/28/22 Hydromorphone waste
7/31/22- waste for Hydromorphone (no date)
1/21/22- MSO4 waste from 1/13/22

Interview with RN (ID C) on 1/24/2023 at 9:30 AM, he stated that because there in only one nurse on duty, all narcotic wastages are to be witnesses with MD on duty.


Interview with facility pharmacist (ID M) on 1/25/2023 at 11:20 AM, when asked what the above comments meant, she stated that during her audit of documentation that signatures for controlled substances were missing she would make note to verify wastage and obtain signatures.

C. Observation on 1/24/2023 at 0930 during facility tour, RN (ID C) obtained access to the pharmacy. A facility document titled " Access to Pharmacy Log'" was located on the narcotic locked box. The document showed the following information:
Texas State Board of Pharmacy rule 291.75(e) states that "a permanent log of the initials or identification codes that will identify pharmacy personnel by name" must be maintained in the pharmacy.

During an interview with RN (ID C) on 1/25/2023 at 11:20 AM, he confined his name was not on the current document.