HospitalInspections.org

29047

Based on observation, interview, record review, and policy review, the facility failed to ensure:
- The pharmacy was maintained according to hospital policy when the pharmacy was found with multiple cardboard boxes stored on the floor, medication storage refrigerators and freezers were not monitored as required, and the barrier isolator (medication mixing area that minimizes bacteria from entering the medication during the mixing process) maintenance was not completed daily.
- Policies were updated annually as part of the Director of Pharmacy's responsibilities described in his job description
- The registration of pharmacy technicians (non-pharmacist staff who assist in the packaging and mixing of medications, as well as other pharmacy duties, under the supervision of a pharmacist) with the State Board of Pharmacy prior to mixing, packaging and dispensing medications.
- Pharmacy technician competency prior to the technician mixing, packaging, and dispensing medications.
- The investigation of medication near misses, when the director failed to appropriately investigate, educate, and put in place measures to prevent further near misses.

These failed practices and lack of Pharmacist oversight, had the potential to place all patients at risk of administration of contaminated medications, incorrect medications, inaccurate medication doses, and decreased effectiveness of medications stored and mixed in the pharmacy,

The pharmacy dispenses 40,000 to 44,000 medications per month. The facility census was 32.

Please see citations at A491, A492 and A501.

Based on observation, interview and policy review, the facility failed to ensure that the pharmacy was maintained according to hospital policy, when the pharmacy was found with multiple cardboard boxes stored on the floor, medication storage refrigerators and freezers were not monitored as required, and the barrier isolator (medication mixing area that minimizes bacteria from entering the medication during the mixing process) maintenance was not completed daily. This had the potential to lead to infection control issues, contamination of mixed medications, and decreased effectiveness of medications stored and mixed in the pharmacy, which could affect all patients. The facility had three medication refrigerators and one medication freezer. The pharmacy dispenses 40,000 to 44,000 medications per month. The facility census was 32.

Findings included:

1. Record review of the facility's policy titled "Pharmacy Policies and Procedures: Pharmacy Maintenance - General" revised 12/03, showed that the floor of the pharmacy should be free of dirt, cardboard containers, and any other materials.

Record review of the facility's policy titled "Pharmacy Policies and Procedures: Inspection of Drug Storage Areas" revised 04/11, showed that drug storage areas must be appropriately secured and maintained in order to promote product integrity and drugs shall be stored under the proper conditions of light, temperature, moisture, ventilation, segregation, and security. All refrigerators and freezers where medications are stored throughout the hospital shall have their temperatures checked daily. The daily record of theses temperatures shall be recorded for any refrigerator and/or freezer used for medication storage. Pharmacy will monitor all refrigerators and/or freezers used for the storage of vaccines twice a day (beginning and end of business day).

Record review of the facility's policy titled "Pharmacy Policies and Procedures: IV Room: Laminar Flow Hood Maintenance" (also known as barrier isolator maintenance) revised 04/14, showed that routine cleaning of the laminar flow hood shall be documented in the pharmacy. The hood shall be cleaned at the beginning of the shift, prior to each compounding batch, every 30 minutes during continuous compounding, and at the end of the day.

2. Observation on 04/21/14 at 1:50 PM, showed 12 cardboard boxes containing medications were stored on the floor. In the corner of the pharmacy, to the left of the barrier isolator, were six or more boxes stored on the floor, with multiple boxes stacked on top of the boxes on the floor.

3. Record review of medication refrigerator and freezer logs and vaccine refrigerator logs, showed that the facility failed to monitor 77 temperatures out of 886 expected temperatures between November 2013 and April 2014.

4. Record review of "Barrier Isolator/Hood Monthly Clean Log" showed that the facility failed to complete nine daily cleanings out of 172 expected daily cleanings between November 2013 and April 2014.

5. During an interview on 04/22/14 at 3:15 PM, Staff F, Pharmacy Technician, stated that the pharmacy technician scheduled for the day was responsible for ensuring that medication refrigerators and freezers and the barrier isolator were maintained daily.

6. During an interview on 04/23/14 at 8:40 AM, Staff B, Director of Pharmacy, stated the following:
- The pharmacy was small and there wasn't room to store the boxed contents on the pharmacy shelves.
- Medication storage areas, including refrigerators and freezers, should be checked daily.
- The barrier isolator should be cleaned and checked daily.
- He couldn't speak to why the refrigerators, freezers and isolator barrier were not maintained as expected, because it was the responsibility of the pharmacy technicians.

29047

Based on interview, record review and policy review, the facility failed to ensure that essential pharmacy policies were developed and updated annually, as part of the responsibilities described in the Director of Pharmacy's job description. This had the potential to affect all patients through pharmacy procedures that were not accurate or did not meet current pharmacy standards. The facility census was 32.

Findings included:

1. Record review of the facility's policy titled "Pharmacy Policies and Procedures: Scope of Services" revised 11/03, showed that the area that described Pharmacy open and closed hours "Monday through Friday", "Saturday and Sunday" and "Holidays" were blank.

Record review of the facility's policy titled "Pharmacy Policies and Procedures: After-Hours Access to the Pharmacy" revised 06/05, showed that all medications required after hours will be obtained from the after-hours night cabinet or the automated dispensing device (medication storage device that delivers only specific patient medications as ordered by a physician) following established procedures.

Record review of the facility's policy titled "Pharmacy Policies and Procedures: Barrier Isolator: Standard Operating Procedure" revised 04/14, showed that a hands-free sink will be available in the pharmacy.

2. Record review of Staff B's Director of Pharmacy job description (undated), showed that he was responsible for policy and procedure development updates, implementations, and review of the policy and procedures on at least a yearly basis.

3. During an interview on 04/23/14 at 8:40 AM, Staff B confirmed that the pharmacy times were not filled in and that he had left them blank, that the facility did not have an after-hours night cabinet, and that the pharmacy did not have a hands-free sink.

Based on observation, interview, record review and policy review, the Director of Pharmacy failed to:
- Ensure one (Staff A) of three pharmacy technicians (non-pharmacist staff who assist in the packaging and mixing of medications, as well as other pharmacy duties, under the supervision of a pharmacist) was registered with The State Board of Pharmacy.
- Ensure competency for one (Staff A) of three pharmacy technicians prior to the technician mixing, packaging, and dispensing medications.
- Investigate six of six medication near misses (medication errors that do not reach the patient), and to educate and put in place measures to prevent further near misses.

This had the potential to affect all patients in the facility by placing the patients at risk for administration of contaminated medications, incorrect medications or inaccurate medication doses. The pharmacy dispenses approximately 40,000 to 44,000 medications per month. The facility census was 32.

Findings included:

1. In Missouri, any person desiring to assist a pharmacist in the practice of pharmacy shall apply to the Board of Pharmacy for registration as a pharmacy technician. Such applicant shall be, at a minimum, legal working age and shall forward to the board the appropriate fee and written application on a form provided by the board. Such registration shall be the sole authorization permitted to allow persons to assist licensed pharmacists in the practice of pharmacy.

2. Record review of the Director of Pharmacy job description, showed Staff B, Director of Pharmacy, was responsible for:
- The development and maintenance of new employee training program and to ensure that new staff were adequately trained in a timely manner.
- Participation in orientation, education and training programs provided for the pharmacy staff.
- Providing for the education needs of pharmacy staff.
- Assured compliance with local, state, and federal law requirements.
- The counseling and evaluation of employees in a timely fashion according to hospital policy.

3. Record review of the facility's policy titled "Human Resources Policies and Procedures - Credentials Verification" revised 10/07/09, showed that all employees will be properly trained and posses [possess] the necessary credentials to meet specific job requirements. The validity of all required credentials will be verified for applications as a condition of hire.

Record review of the facility's policy titled "Human Resources Policies and Procedures - References & Background Checks" revised 05/14/03, showed that employment references and required licensure will be checked for all applicants before making an offer of employment. Additional background information, including educational credentials will be investigated as required by job responsibilities and in accordance with federal and state law. A primary source verification of all credentialed personnel must be kept in the employee's file and the credential and/or a copy of the credential is placed in the employee's personnel file.

4. Record review of the employment record for Staff A, former employee, showed the following:
- A Pharmacy Technician job description, which showed it should include orientation, performance evaluation and competency skills, was signed by Staff A and dated 07/18/13. The position qualifications showed that the staff member must work efficiently under broad guidelines established by the State Board of Pharmacy. The orientation, performance evaluation and competency skills were not included in the record.
- A formal letter addressed to Staff A, dated 07/29/13, showed Staff A's title was "Telemetry Technician/PRN (as needed) Pharmacy Technician" effective 07/26/13, was signed by Staff D, Human Resources (HR) Coordinator (undated signature) and Staff A on 07/30/13.
- No documentation of State Board of Pharmacy registration as a pharmacy technician.
- No documentation of pharmacy technician competencies

5. During an interview on 04/22/14 at approximately 1:30 PM, Staff D, stated that Staff A was "going to do some stuff in pharmacy", so she had her sign the Pharmacy Technician Job Description. Staff D stated that she was new to the HR Coordinator position, new to the medical field and didn't realize that pharmacy technicians required registration with the State Board of Pharmacy. "That was my fault and I take full responsibility for that." Staff D stated that she found out that Staff A required registration with the State, when Staff A informed her of the requirement, after she began a second job as a pharmacy technician in another hospital, and found she did not meet the minimum requirements to function as a pharmacy technician without the registration.

6. During a telephone interview on 04/23/14 at 3:00 PM, Staff A, stated the following:
- Staff B, Director of Pharmacy, asked her to cross-train in the pharmacy.
- She trained and functioned as a pharmacy technician from July through September, 2013, to assume a PRN position as a pharmacy technician.
- Staff B requested approval through Staff D, HR Coordinator, for Staff A to access Pharmacy specific computer programs, so that she could complete pharmacy technician duties.
- When she worked in the pharmacy, she was required to contact Staff D to ensure that timekeeping accurately showed where she worked so that she would be paid from the correct department.
- She was oriented by Staff F, Pharmacy Technician, who followed orientation guidance provided by Staff B.
-When she oriented in the Pharmacy, she stocked medication shelves, refilled medication dispensaries (computerized medication storage that releases only patient specific medications as ordered by a physician), mixed intravenous (IV - administered in the vein) medication and packaged and labeled medications.
- Her orientation included documented competency verification, which was signed off by Staff F, and remained in the Pharmacy, which she did not retain a personal copy of.
- She observed IV medication mixing by other pharmacy technicians for the first two or three weeks of her orientation, then Staff F, had her practice mixing IV medications under Staff F's observation, then she mixed approximately 15 - 20 IV medications and packaged and labeled medications "a handful of times", both without supervision.
- Pharmacists, including Staff B, signed (indicated the Pharmacist verified the medication was correct) the IV medications she had mixed and the medications she had packaged.
- All pharmacy staff who worked with her knew she performed these duties without direct supervision.
- She did not realize she needed to be registered (application process with the State Board of Pharmacy) to work as a pharmacy technician before she functioned as a pharmacy technician in the hospital.
- The State Board of Pharmacy found that she was not registered as a pharmacy technician, contacted the facility, then spoke with her and informed her that they would conduct an investigation and would come to the hospital for interviews.
- "That was when everything (Staff A's work in the Pharmacy) stopped."

7. During an interview on 04/22/14 at 3:15 PM and 4:19 PM, Staff F, Pharmacy Technician, stated that Staff A:
- Pulled medications from the pharmacy to refill the medication dispensary stock.
- Never mixed any IV medications.
- Did not have a pharmacy technician title, but planned to assume a PRN position as a pharmacy technician.
- "Really didn't do much, just observed mostly".
- Was "licensed and registered" with the State Board of Pharmacy (there is no licensure requirement in the State of Missouri).

8. Record review of the facility's policy titled, "Pharmacy Policies and Procedures - Sterile Preparations: IV Admixture Service" revised 04/13, showed the following:
- The Director of Pharmacy is responsible for managing the IV compounding systems to ensure that IV products are sterile and stable throughout the administration process.
- All pharmacy personnel who may prepare IV admixtures must show competence in aseptic technique concepts.
- Pharmacy personnel training shall occur during initial orientation and at least annually thereafter.
- Competency must be documented and placed in the personnel files.

9. During an interview on 04/22/14 at 4:19 PM, Staff B, Director of Pharmacy, stated that Staff A:
- Never had the title Pharmacy Technician.
- Never completed a competency checklist because she only "shadowed" (to observe only), and never performed any hands on duties while in the pharmacy.
- Did not mix IV fluids, did not package and label medications and did not restock the medication dispensary.
- Did not have access to the medication dispensary.
- Was not paid while shadowing in the pharmacy.
- Was never scheduled as the second pharmacy technician.
- Was not registered as a pharmacy technician with the State Board of Pharmacy.

10. Record review of Staff A's timekeeping record dated 07/16/13 through 08/29/13, showed that she worked in the pharmacy (indicating she was paid) on 08/06/13, 08/07/13, 08/13/13, 08/15/13, 08/16/13, 08/19/13, 08/20/13, 08/21/13, 08/23/14, 08/26/13 and 08/28/13, based on clock-in and clock-out times correlating with pharmacy hours of 8:00 AM through 4:30 PM.

11. Record review of the facility's policy titled, "Pharmacy Policies and Procedures - Barrier Isolator: Standard Operating Procedure" revised 04/14, showed that only individuals with documented completion of the training program may compound sterile preparations in the pharmacy.

Record review of the facility's policy titled, "Pharmacy Policies and Procedures - Sterile Preparations: Staff Training and Quality Assurance" revised 03/08, showed that compounding of sterile preparations requires a staff competent in compounding techniques to avoid particle and bacterial contamination. The policy also showed the following directions:
- Prior to compounding any compounded sterile products for patient use, each employee must successfully complete all sections of training, which included didactic training from audio/video/website instructional sources and/or professional publications in the principles and practical skill of aseptic manipulations which included proper hand washing technique, function of laminar flow and/or barrier isolator hoods, proper cleaning of hood and IV compounding supplies, dosage calculations, appropriate techniques to open vials and ampules, as well as others.
- Hands on demonstration of sterile product compounding techniques.
- Trainees should initially complete and pass three tests related to minimizing contamination of sterile products as well as other tests.
- Initial testing and orientation check-off should be documented in employees education file.

Record review of the facility's policy titled, "Pharmacy Policies and Procedures - Sterile Preparations: IV Admixture Service" revised 04/13, showed the following:
- The Director of Pharmacy is responsible for managing the IV compounding systems to ensure that IV products are sterile and stable throughout the administration process.
- All pharmacy personnel who may prepare IV admixtures must show competence in aseptic technique concepts.
- Pharmacy personnel training shall occur during initial orientation and at least annually thereafter. Competency must be documented and placed in the personnel files.

12. Record review of Pharmacy documents showed the following:
- A medication dispensary "Operator Maintenance Activity" report showed that on 08/06/13, Staff B "added operator" Staff A, former employee.
- Staff A's "Medication Dispensary Profile" showed that she was able to return medications to stock, complete patient maintenance (make changes to patient profiles), manage medication inventory, inventory controlled substances, and access patient and inventory reports.
- A medication dispensary "Operator Transactions" report for the month of February, showed 115 pages of activity (approximately eight transactions per page) by Staff A, which included that she accessed the medication dispensary to stock patient medications, inventory medications and correct medication counts.
- A "Drug Prepacking Log" for 2013, showed that medications were packaged and labeled by Staff A and reviewed and signed by Staff B.
- A "Barrier Isolator/Hood Monthly Clean Log" (log of required care to ensure the area used to mix IV medications was maintained and clean as possible), showed that on 08/28/13, Staff A completed and signed that she had cleaned the hood before mixing IV medications, documented the hood control (measurement of exhaust) and attached gloves (remain inside the hood, hands are inserted through an opening and into the gloves to ensure cleanliness while mixing medications) to the inside of the hood.
- The Pharmacist Schedule for August 2013, showed that Staff B, Director of Pharmacy, worked 10 of the 11 days that Staff A worked in the pharmacy during 08/13, which indicated he should have been aware of the tasks that Staff A completed while they worked together.
- The Pharmacy Technician Schedule for August 2013, showed that Staff F, Pharmacy Technician, worked nine of the 11 days that Staff A worked in the pharmacy during 08/13, which indicated she should have been aware of the tasks that Staff A completed while they worked together.

13. Throughout the survey, even after records indicated that Staff A performed hands on tasks that were specific to the role of a pharmacy technician, Staff B, Director of Pharmacy, continued to deny that Staff A performed any duties while working in the pharmacy and that she only shadowed pharmacy technician staff.

14. Record review of the facility's policy titled "Pharmacy Policies and Procedures : Medication Errors" revised 04/14, showed that by definition, medication errors were any circumstances, actions or failures to act that may or do lead to variances from the intended use of drugs within the institution. "Near Miss" (medication errors that does not reach the patient) will be recorded and evaluated, and a completed incident report (documents the details of the incident, the findings that led to the incident, and any follow-up - coaching, discipline, education, etc) is forwarded to the Quality Manager. The reports are reviewed and trended. A flow chart attached to the policy and procedure showed that once a medication error or near miss was found, the details of the incident report were to be forwarded to the "Immediate Supervisor to investigate and analyze, documenting on the back of form".

15. Observation, with concurrent interview on 04/21/14 at 3:45 PM, showed Staff O, Pharmacy Technician, removed medications from stocked bins in the pharmacy and placed them with an inventory list used to stock medication dispensaries. The medications and list were placed next to Staff B, Director of Pharmacy, who verified that the medications removed from the pharmacy bins were the correct medication and dosages on the list. Staff B signed the list after review, and Staff O then took the medications to the medication dispensaries. Staff O stated that the Pharmacist reviews all medications for accuracy prior to removal of the medication from the pharmacy.

16. Record review of incident reports showed the following:
- On 12/02/13 at 11:44 PM, when a nurse went to remove the medication Tylenol (mild pain reliever/fever reducer) for administration to a patient, Aspirin (reduces the bloods ability to clot) was found in the medication dispensary drawer.
- On 12/03/13 at 5:28 AM, when a nurse went to remove the medication Compazine (reduces nausea and vomiting) for administration to a patient, Phenergan (reduces nausea and vomiting) was found in the medication dispensary drawer.
- On 12/05/13 at 10:00 PM, when a nurse went to remove the medication Florastar (contains yeast and bacteria to promote digestion) for administration to a patient, Renvela (used to reduce elevated phosphate levels in patients with kidney disease) was found in the medication dispensary drawer.
- On 02/02/14 at 8:50 PM, when a nurse went to remove Heparin (blood thinning medication) for administration to a patient, Magnesium Sulfate (a high risk medication that replaces low magnesium in the body, and can be fatal if administered without first being diluted) was found in the medication dispensary drawer. Further documentation by the nurse who completed the incident report showed that the bottles of Magnesium Sulfate have orange tops like Heparin, and 25 vials of the Magnesium Sulfate were found in the drawer.
- On 03/01/14 at 11:50 PM, when a nurse went to remove the medication Heparin for administration to a patient, Magnesium Sulfate was found in the medication dispensary drawer. Further documentation by the nurse completing the incident report showed that she wrote, "This is the third time nursing has found magnesium sulfate mixed in with the Heparin.

17. During an interview on 04/23/14 at 10:47 AM, Staff C, Director of Quality Management, stated that the incident reports had not been investigated. Staff C stated that the facility would not be able to determine who made the errors when stocking the medications in the medication dispensary, or determine the Pharmacist who was responsible for reviewing the medications for accuracy, prior to being removed from the Pharmacy. Staff C stated that the only option to address and educate staff involved in the near miss, would be to pull the Pharmacist and Pharmacy Technician schedule and speak to everyone scheduled during the time of the error. After surveyor prompting, Staff C agreed that a report could be generated from the medication dispensary activity report, to determine who had stocked the medications incorrectly.

18. During an interview on 04/23/14 at 11:30 AM, Staff B, Director of Pharmacy, stated that he "believed" the Magnesium Sulfate near misses were made by Staff P, Pharmacy Technician, but did not know who was responsible for the other near misses.

During an interview on 04/23/14 at 4:45 PM, Staff B stated that he now knew who made the medication near misses, Staff P and Staff F, Pharmacy Technician. Staff B stated that he didn't know which pharmacist(s) was responsible for review of the medications prior to the removal of the medications from pharmacy, because not all pharmacists signed the inventory list after they reviewed it for accuracy. Staff B added that he discussed the near misses with all of pharmacists, but didn't document the discussions or the attendance because it wasn't a formal discussion and because he didn't see any trends. Staff B stated that there had been no changes made to the medication dispensing process because of the medication near misses.

19. Record review of email correspondences dated 03/03/14 showed that Staff B, Director of Pharmacy, informed Staff P, Pharmacy Technician, of two of the reported Magnesium Sulfate near misses. "You put magnesium vials in the heparin drawer ...There (sic) are look alike vials and I assume that this is how it happened ...Just saying be careful with these particular drugs ...Also, make sure that the pharmacist checks the meds you pull ...for accuracy". There was no indication that further education or training was provided to the staff member.

20. Record review of Staff P's and Staff F's, Pharmacy Technicians, employment record showed no coaching, counseling or disciplinary action, and no evidence of further training related to the near misses.

Based on observation, interview, record review, and policy review, the facility failed to ensure medications were kept secure, locked and assessable only to authorized persons for two patients (#2 and #3) of three observed with unsecured medications at their bedside and/or unsecured on a work station on wheels (WOW, mobile medication cart used by nursing staff) in the patient and visitor hallway. The failure to ensure medications were safe from tampering, diversion and available for administration as ordered by the physician had the potential to affect all patients admitted to the facility. The facility census was 32.

Findings included:

1. Record review of the facility's policies showed no policy for security of medications in patient care areas. Even though requested, the facility failed to provide policies that provided staff direction for medication security and storage to prevent unauthorized access to medications in patient care areas.

2. Observation on 04/23/14 at approximately 10:00 AM showed one unsecured intravenous (IV, in the vein) antibiotic (a medication used to treat infection) fluid bag of Zoysyn (a type of medication used to treat infections) for Patient #2 lying unsecured on top of a WOW located in the hallway outside of Patient #2's room.

Observation on 04/23/14 at approximately 10:10 AM in Patient #2's room showed two open vials of eye drops at the patient's bedside. The vials were two distinct medications each medication was labeled and dated 04/08/14. The vials were labeled Latanoprost 0.005% solution (a medication used to reduce intraoccular pressure), one drop to both eyes at bedtime and Travatan 0.0004% solution (a medication used to reduce intraoccular pressure), one drop in both eyes daily.

3. During an interview on 04/23/14 at approximately 10:00 AM, Patient #2 stated that the nurses administered eye drops to him every day.

4. During an interview on 04/23/14 at approximately 10:15 AM Staff J, Registered Nurse (RN) who had dispensed medications from the WOW at the time when Patient #2's IV medication was observed unsecured, stated that she did not remove the medication from the WOW and did not know who left the medication unsecured on top of the WOW. She stated that all medications should have been secure at all times. She stated that she was not sure if the facility had a policy for the security of medications kept at the patient's bedside.

5. Record review of Patient #2's medication administration record (MAR) showed the following medications were distributed by the facility pharmacy per physician orders dated 04/08/14; Latanoprost 0.005% solution and Travatan 0.0004% solution.

6. Observation on 04/23/14 at 9:40 AM in Patient #3's room showed one open tube of Bactroban 2% antibiotic ointment (a medication applied to the skin to treat infection) lying unsecured on the patient's bedside table.

7. During an interview on 04/23/14 at 9:40 AM, Patient #3 stated that the medicine was kept in her room and the nurses placed the medicine on a swab and she put it up her nose every day.

8. Record review of Patient #3's MAR showed Bactroban 2% antibiotic ointment was ordered by the patient's physician on 03/29/14 and did not include orders for the medication to be left at the patient's bedside or for the medication to be self-administered by the patient.

9. During an interview on 04/23/14 at approximately 9:40 AM Staff H, RN stated that she was aware that medications should have a physician order when kept at the bedside and should have been kept secure when left in patient rooms. However, she stated that the patient rooms did not have a secure place to put medications and they were kept any place the nurses or patients could find them when needed. She stated that she was not aware of a policy that gave the staff direction where to secure medications when kept at the bedside. She stated that the facility was different, in that, other facilities required a physician order for medications left at the bedside and the medications were kept locked in the patient rooms.

10. During an interview on 04/23/14 at 10:15 AM Staff I, Charge Nurse, stated that medication should not be left on top of the WOW's at any time if the nurse isn't at the WOW. She stated that all medication should be secured at all times, including in patient rooms. She stated that she was not sure if the facility had a policy that gave staff direction on how to store medications in patient care areas, however, they should just know not to leave medication unsecured because it was a standard of care in hospitals. If located, she agreed to provide a policy related to medication storage and security in patient care areas. Staff I did not provide a policy.

11. During an interview on 04/23/14 at approximately 10:45 AM Staff B, Director of Pharmacy (DOP), stated that Staff E, Pharmacist, placed Patient #2's IV medication on the WOW and left it unsecured because she was busy. Staff B stated that the pharmacist should have placed the medication in the patient's locked bin. He stated that no monitoring was in place to ensure medications were secure in patient care areas. He stated that once the medications were distributed from the pharmacy it was the Nursing Department's responsibility to oversee the security and storage of medications and that he thought the nursing department had policies regarding security and storage of medications in patient care areas.