HospitalInspections.org

Based on observation, document review, and interview, for one of one OR/Operating Room (Room #4) observed, the hospital failed to ensure that medications in the OR were kept secured, as required by policy.

Findings include:

1. On 10/31/2025 between 10:30 AM through 12:00 PM, observational tour of the hospital's OR/Operating Room, was conducted. At approximately 12:00 PM, inside OR Room 4 was an unlocked anesthesia cart. The cart had three vials of unopened fentanyl injection (sedating agent).

2. On 10/31/2025, the hospital's OR policy titled, "Medications in the OR" (8/2025) was reviewed and indicated, "... I. Policy: Ensure that the safe medication practices are followed within the intra-operative setting... IV. security of Medications. 1. All medications should be secured... 2. Anesthesia cart should be locked..."

3. On 10/31/2025 at approximately 12:00 PM, findings were discussed with E #2 (OR RN). E #2 stated that OR Room can be accessed by staff who are not allowed to handle medications. E #2 stated that the anesthesia cart should be locked at all times. E #2 stated that the anesthesiologist prepared the medication, and should have locked the cart.