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Based on record review and interview, the hospital failed to ensure administrative oversight of the contracted pharmacy service provider by failing to identify and correct deficiencies, prior to this survey, relating to incomplete and/or inaccurate controlled drug inventory records regarding the disposition of controlled drugs that enter the hospital. Findings:

Review of the perpetual inventory records for Oxycodone/APAP 10/325 (Percocet 10), Hydrocodone/APAP 7.5/500 (Lortab 7.5/500), and Diazepam 5mg revealed that the records were incomplete and/or inaccurate.

The hospital's policy/procedure titled "Pharmacy Narcotic Inventory" was reviewed. The purpose of the policy/procedure is documented as "To ensure accountability and accuracy of all controlled substances in the Drug room". The policy/procedure further documents "A perpetual controlled substances inventory will be maintained" and "An inventory audit will be done at least twice yearly by the pharmacist and another designated employee". The policy/procedure further documents "An annual review of the narcotics inventory will be performed by the administrator or designee".

The "Pharmacy and Therapeutics Committee Meeting" minutes for the most recent two meetings were requested for review. This review revealed committee meetings dated 2/25/10 and 7/15/10. Review of the meeting minutes revealed no documentation to indicate that the hospital had identified that the perpetual inventory records for controlled drugs were incomplete and/or inaccurate.

In an interview on 10/07/10 at 10:50 a.m., the hospital's Administrator/Chief Executive Officer (S1) reported that he could provide no documentation to indicate that an annual review of the narcotics inventory had been conducted by the administrator or designee as documented in the policy/procedure. S1 indicated there was no oversight of pharmacy to ensure the documentation for the accurate disposition of controlled drugs was maintained and current.

Based on record reviews and interviews, the hospital failed to ensure 1) a post operative patient was reassessed following the administration of pain medication 2) a post operative patient received breathing treatments as ordered by the attending physician or that the attending physician had been notified of the missed dose of medication 3) the implementation of appropriate infection control nursing interventions as evidenced by the nurses decision to reconnect the tubing to a port on Patient #1's indwelling Foley Catheter after the tubing was found disconnected from the patient and lying on the floor in a puddle of blood tinged urine
4.spiked bags of Intravenous (IV) 0.9% Sodium Chloride and tubing were dated, timed and had the name of the staff member that spiked the IV bag .(#12, #2, #17, #1) Findings:

1. Review of the medical record for Patient #12 revealed she was a post operative patient that had a total abdominal hysterectomy with bilateral salpingoopherectomy on 7/27/2010. Further review revealed on 7/28/2010 at 3:35 p.m. she had a pain scale of 5/10 and was complaining of pain and discomfort to her lower abdomen. Lortab 10 mg was given as ordered. Review of the nurses notes revealed no documentation that the patient had been reassessed for pain following the administration of Lortab 10 mg. Review of pain management section of her medical record revealed the next assessment for pain was at 7:15 pm which was 3 hours and 45 minutes after the administration of Lortab and her pain at that time was rated as a 4/10.

An interview was held with S3 RN and S5 Chief Nursing Officer on 10/4/2010 at 11:00 a.m. After review of the medical record for Patient #12 they indicated there was no documentation in the medical record that the patient had been reassessed for pain after the administration of Lortab 10 mg. S3 and S5 indicated they expected the nurses in the hospital to reassess a patient after pain medication had been administered.

Review of the hospital policy titled charting Administration of Medications revealed in part "...Administered medications will be charted using the following procedure: Patient response to medications..."

Review of the medical record of Patient #2 revealed that the patient was admitted to the hospital on 6/18/10. Patient #2's admission diagnoses included left rotator cuff tendinitis, left subacromial impingement, left subacromial bursitis, and left superior labrum anterior and posterior tear. Review of the operative report revealed that the procedures performed on Patient #2 were Arthroscopic subacromial decompression, Arthroscopic bursectomy, Arthroscopic glenohumeral synovectomy, extensive, Arthroscopic rotator cuff debridement, and Arthroscopic superior labrum anterior and posterior tear reconstruction with 3 anchors. Review of the nursing documentation revealed an entry dated 6/20/10 at 9:25 a.m. indicating that 75mg of Demoral was administered intramuscular to Patient #2. Further review of the nursing documentation revealed an entry dated 6/20/10 at 10:00 a.m. indicating that Patient #2 was discharged from the hospital which was within 35 minutes of the administration of IM Demoral. Review of the record revealed no documentation to indicate that a reassessment was conducted on Patient #2 prior to discharge on 6/20/10 following the recent administration of IM Demoral. In an interview on 10/05/10 at 9:20 a.m., the Compliance Officer (S3) reviewed the medical record and confirmed there was no documentation to indicate that a reassessment was conducted on Patient #2 prior to discharge on 6/20/10 following the recent administration of IM Demoral


2. Review of the medical record for Patient #17 revealed he had a lumbar decompression fusion of L4 and L5 on 7/8/2010. Further review revealed physician orders for "...Albuterol 2.5 mg/3 ml unit dose nebulizer q 4 hr..." Review of the medication administration record revealed no documentation the patient received the 6:00 p.m. dose of Albuterol 2.5 mg/3 ml on 7/9/2010.

An interview was held with S3 RN and S5 Chief Nursing Officer on 10/4/2010 at 10:30 a.m. After review of the medication administration record for Patient #17 and the nurses notes on 7/9/2010, they indicated there was no documentation in the nurses notes or on the MAR to indicate the patient had received his 6:00 p.m. dose of Albuterol 2.5 mg/3 ml on 7/9/2010 or that the physician had been notified of the missed dose of medication.

3. Review of the medical record for Patient #1 revealed that the patient was admitted to the hospital on 10/01/10. Review of the nursing documentation revealed an entry dated 10/03/10 at 6:30 p.m. that read "Foley Catheter bag and tubing disconnected from port, Foley lying on floor in puddle of blood tinged urine. Foley bag & tubing reconnected to port".

The Chief Nursing Officer reviewed the nursing entry dated 10/03/10 at 6:30 p.m. In an interview on 10/05/10 at 8:30 a.m., the Chief Nursing Officer indicated that new tubing should have been used on Patient #1 and that the contaminated tubing should not have been reconnected to the port.

4. An observation was made in the recovery room on 10/4/10 at 11:55 of 6 spikes bags of 0.9% Sodium Chloride at the head of 6 unoccupied stretchers. Further observation revealed that the spiked bags of Sodium Chloride and tubing were not dated, timed, or had the name of the staff member that spiked the IV bag .

An interview was held with S2 RN at the time of this observation. She indicated that the IV bags of 0.9% Sodium Chloride and tubing were not dated, timed or had the name of the staff member that spiked the IV bag .

Based on record review and interview, the hospital failed to ensure that the pharmacist provided oversight relating to the disposition of controlled drugs that are received in the hospital. This was evidenced by the pharmacist failing to ensure that the perpetual inventory of controlled drugs was complete and accurate in accordance with State and Federal Laws for 3 of 3 controlled drugs reviewed. Findings:

1. Oxycodone/APAP 10/325 (Percocet 10)

Review of the perpetual inventory for the Oxycodone/APAP 10/325 (Percocet 10) was reviewed with the pharmacist on 10/05/10 at 2:15 p.m. This review revealed that the perpetual inventory for this controlled drug was incomplete in that the documentation on the perpetual inventory report indicated a count of 380 tablets of Oxycodone/APAP 10/325 (Percocet 10) in the pharmacy on 7/03/10 and 220 tablets in the pharmacy on 9/20/10 (multiple spaces or lines were not completed or blank between the dates of 9/20/10 and 7/03/10). There was no documentation to indicate 1) the disposition of this controlled drug as there were no entries on the perpetual inventory to identify the date or time the controlled drugs were removed from pharmacy; 2) the number of tablets of this controlled drug removed from pharmacy; or 3) the destination of this controlled drug once removed from pharmacy. This lack of documentation by the pharmacist resulted in S8's inability to describe the disposition of the 160 tablets of Oxycodone/APAP 10/325 (Percocet 10). S8 reported that she would have to rely on the nursing shift count reports to track the disposition of these controlled drugs.

The Chief Executive Officer (S1) was interviewed on 10/05/10 at 3:05 p.m. S1 confirmed that the perpetual inventory relating to the Oxycodone/APAP 10/325 (Percocet 10) was incomplete in that the perpetual inventory failed to indicate the disposition of this controlled drug once received in the hospital.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/05/10 at 3:10 p.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Oxycodone/APAP 10/325 (Percocet 10) received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Oxycodone/APAP 10/325 (Percocet 10) tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5.

2. Hydrocodone/APAP 7.5/500 (Lortab 7.5/500)

The contracted pharmacist (S8) was interviewed on 10/06/10 at 8:30 a.m. regarding the actual inventory count and disposition of the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets that have been received in the hospital. The actual count in the pharmacy on 10/06/10 at 8:30 a.m. was 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500).

The perpetual inventory for the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was reviewed with the pharmacist on 10/06/10 at 8:30 a.m. This review revealed that the perpetual inventory for this controlled drug was incomplete and inaccurate in that the documentation on the perpetual inventory report indicated a count of 60 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) in the pharmacy with the most recent entry dated 8/03/10 resulting in 10 tablets being unaccounted for. When asked about this discrepancy, the pharmacist reviewed the perpetual inventory and actual count and after recounting reported that there were a total of 70 Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets on hand in the pharmacy. Review of the drug labels of the 70 tablets provided by the pharmacist revealed that the pharmacist was counting Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) in the count with the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) as there were 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and 20 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650). The pharmacist confirmed the count of 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and 20 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) and stated that she does not separate the two different strengths of Lortab (Lortab 7.5/500 and Lortab 7.5/650) on the perpetual inventory sheet. The pharmacist explained that she uses the same perpetual inventory sheet for both the Lortab 7.5/500 and the 7.5/650 resulting in the pharmacist inability to determine the disposition of Lortab 7.5/500 tablets received in the hospital and the disposition of Lortab 7.5/650 received in the hospital.

The pharmacy vendor reports were reviewed. This review revealed that a delivery of 500 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) was received on 2/26/09 and a delivery of 100 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was received on 7/22/10.

Documentation on the perpetual inventory for the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) revealed that the pharmacist has been combining and continues to combine the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets and the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets on the same perpetual inventory record as reported by the pharmacist.

The Chief Executive Officer (S1) was interviewed on 10/06/10 at 8:35 a.m. S1 confirmed that the perpetual inventory relating to the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was incomplete and inaccurate.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/06/10 at 8:35 a.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets and the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5. S3 and S5 reported that the perpetual inventory report provided by the pharmacist was not complete or accurate.

3. Diazepam 5mg

The contracted pharmacist (S8) was interviewed on 10/06/10 at 9:50 a.m. regarding the actual inventory count and disposition of Diazepam 5mg tablets that have been received in the hospital. The actual count in the pharmacy on 10/05/10 at 2:15 p.m. was 105 Diazepam 5mg tablets.

The perpetual inventory for the Diazepam 5mg tablets was reviewed with the pharmacist on 10/06/10 at 9:50 a.m. This review revealed that the perpetual inventory for this controlled drug was incomplete in that the documentation on the perpetual inventory report failed to indicate the disposition of the 5mg tablets of Diazepam.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/06/10 at 10:00 a.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Diazepam 5mg tablets received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Diazepam 5mg tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5.

The hospital's policy/procedure titled "Pharmacy Narcotic Inventory" was reviewed. The purpose of the policy/procedure is documented as "To ensure accountability and accuracy of all controlled substances in the Drug room". The policy/procedure further documents "A perpetual controlled substances inventory will be maintained" and "An inventory audit will be done at least twice yearly by the pharmacist and another designated employee". The policy/procedure further documents "An annual review of the narcotics inventory will be performed by the administrator or designee".

In an interview on 10/07/10 at 10:50 a.m., the hospital's Administrator/Chief Executive Officer (S1) reported that he could provide no documentation to indicate that an annual review of the narcotics inventory had been conducted by the administrator or designee as documented in the policy/procedure.

The "Pharmacy and Therapeutics Committee Meeting" minutes for the most recent two meetings were requested for review. This review revealed committee meetings dated 2/25/10 and 7/15/10. Review of the meeting minutes revealed no documentation to indicate that the hospital had identified that the perpetual inventory records for controlled drugs were incomplete and/or inaccurate.

Based on record review and interview, the hospital failed to ensure that outdated drugs were not available for patient use by failing to ensure that outdated drugs were removed from the malignant hyperthermia cart and the crash cart in the surgical services section of the hospital and from the crash cart on the hospital's inpatient unit. Findings:

Observations in the surgical services area on 10/5/10 at 9:15 a.m. revealed the malignant hyperthermia cart had two (2) vials, each containing Furosemide 40 mg, with an expiration date of 9/1/10. Further observations made of the crash cart located in the recovery room revealed
two (2) vials of 250mg of Aminophylline with an expiration date of 8/14/10, and a 1000 milliliters bag of Lactated Ringers with an expiration date of 4/2010. An interview was held with S7 at the time of these observations. S7 indicated the pharmacist was responsible for ensuring that outdated drugs were removed from the malignant hyperthermia cart and the crash cart and replaced with drugs that are not expired.

Observations on the inpatient unit on 10/05/10 at 9:30 a.m. revealed two (2) vials, each containing 250mg of Aminophylline, with an expiration date of 8/01/10. The inpatient unit charge nurse (S18) was interviewed at the time of this observation (10/05/10 at 9:30 a.m.) and confirmed that the vials of Aminophylline were expired as of 8/01/10. S18 reported the pharmacist was responsible for ensuring that outdated drugs were removed from the crash cart and replaced with drugs that are not expired.

Based on record review and interview the hospital failed to ensure that physicians caring for patients in the hospital were free from a communicable disease,Terberculosis, (TB) as evidence by 7 of 7 physician credentialing files reviewed having no documentation that the attending physicians were free from Terbuculosis.( S11MD, S12MD, S13MD, S14MD, S15MD, S16MD, S17MD) Findings:

Review of the credentialing files for S11MD, S12MD, S13MD, S14MD, S15MD, S16MD, S17MD revealed no documentation that these physicians currently on staff and providing patient care at the hospital were free from Terbuculosis.

An interview was held with S3 RN Compliance Officer on 10/7/2010 at 9:20 am. She indicated the hospital did not require physicians to have TB tesing before caring for patients in the hospital. She further indicated the hospital did not have a policy related to TB testing for physicians.

Based on record reviews and interview the hospital failed to ensure accurate data was captured and reported related to surgical site infections as evidenced by reporting surgical site infection rates monthly when not all physicians had reported their surgical site infection rates back to the hospital. Findings:

Review of the Infection Control Report for surgical site infections from January 2010 to September 2010 revealed 24 physicians were querried for their surgical site infection rate. Further review revealed 2 of the 24 physicians had never reported their data, and 6 of the 24 physicians had reported their surgical site infection rates from 14% to 86% of the time with an average return rate for all physicians at 81%.

An interview was held with S3 RN Complainace on 10/7/2010. She indicated the hospital staff calls patients about one week post operatively to check on infections. She added the attending physicians are sent a letter monthly to report surgical site infections. After review of the documentation, S3 RN indicated that the data she reported was not accurate since she had not recieved documentation from all of the physicians on the months she had reported on 2010.

Review of the hospital Policy titles Infection Control revealed in part "...Collection of Data: Cumulative data will be evaluated and presented to the ICC for analysis and evaluation on a monthly basis..."

Based on record reviews of the perpetual inventory list for controlled drugs, P&T Committee Meeting Minutes, monthly Performance Improvement Pharmacy Report and interviews the hospital failed to identify through the QA process that the perpetual inventory of controlled drugs were incomplete and inaccurate as evidence by controlled drugs not being reconciled by the pharmacist.Findings:

1. Oxycodone/APAP 10/325 (Percocet 10)

Review of the perpetual inventory for the Oxycodone/APAP 10/325 (Percocet 10) was reviewed with the pharmacist on 10/05/10 at 2:15 p.m. This review revealed that the perpetual inventory for this controlled drug was incomplete in that the documentation on the perpetual inventory report indicated a count of 380 tablets of Oxycodone/APAP 10/325 (Percocet 10) in the pharmacy on 7/03/10 and 220 tablets in the pharmacy on 9/20/10 (multiple spaces or lines were not completed or blank between the dates of 9/20/10 and 7/03/10). There was no documentation to indicate 1) the disposition of this controlled drug as there were no entries on the perpetual inventory to identify the date or time the controlled drugs were removed from pharmacy; 2) the number of tablets of this controlled drug removed from pharmacy; or 3) the destination of this controlled drug once removed from pharmacy. This lack of documentation by the pharmacist resulted in S8's inability to describe the disposition of the 160 tablets of Oxycodone/APAP 10/325 (Percocet 10). S8 reported that she would have to rely on the nursing shift count reports to track the disposition of these controlled drugs.

The Chief Executive Officer (S1) was interviewed on 10/05/10 at 3:05 p.m. S1 confirmed that the perpetual inventory relating to the Oxycodone/APAP 10/325 (Percocet 10) was incomplete in that the perpetual inventory failed to indicate the disposition of this controlled drug once received in the hospital.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/05/10 at 3:10 p.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Oxycodone/APAP 10/325 (Percocet 10) received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Oxycodone/APAP 10/325 (Percocet 10) tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5.

2. Hydrocodone/APAP 7.5/500 (Lortab 7.5/500)

The contracted pharmacist (S8) was interviewed on 10/06/10 at 8:30 a.m. regarding the actual inventory count and disposition of the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets that have been received in the hospital. The actual count in the pharmacy on 10/06/10 at 8:30 a.m. was 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500).

The perpetual inventory for the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was reviewed with the pharmacist on 10/06/10 at 8:30 a.m. This review revealed that the perpetual inventory for this controlled drug was incomplete and inaccurate in that the documentation on the perpetual inventory report indicated a count of 60 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) in the pharmacy with the most recent entry dated 8/03/10 resulting in 10 tablets being unaccounted for. When asked about this discrepancy, the pharmacist reviewed the perpetual inventory and actual count and after recounting reported that there were a total of 70 Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets on hand in the pharmacy. Review of the drug labels of the 70 tablets provided by the pharmacist revealed that the pharmacist was counting Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) in the count with the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) as there were 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and 20 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650). The pharmacist confirmed the count of 50 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and 20 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) and stated that she does not separate the two different strengths of Lortab (Lortab 7.5/500 and Lortab 7.5/650) on the perpetual inventory sheet. The pharmacist explained that she uses the same perpetual inventory sheet for both the Lortab 7.5/500 and the 7.5/650 resulting in the pharmacist inability to determine the disposition of Lortab 7.5/500 tablets received in the hospital and the disposition of Lortab 7.5/650 received in the hospital.

The pharmacy vendor reports were reviewed. This review revealed that a delivery of 500 tablets of Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) was received on 2/26/09 and a delivery of 100 tablets of Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was received on 7/22/10.

Documentation on the perpetual inventory for the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) revealed that the pharmacist has been combining and continues to combine the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets and the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets on the same perpetual inventory record as reported by the pharmacist.

The Chief Executive Officer (S1) was interviewed on 10/06/10 at 8:35 a.m. S1 confirmed that the perpetual inventory relating to the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) was incomplete and inaccurate.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/06/10 at 8:35 a.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) tablets and the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Hydrocodone/APAP 7.5/500 (Lortab 7.5/500) and the Hydrocodone/APAP 7.5/650 (Lortab 7.5/650) tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5. S3 and S5 reported that the perpetual inventory report provided by the pharmacist was not complete or accurate.

3. Diazepam 5mg

The contracted pharmacist (S8) was interviewed on 10/06/10 at 9:50 a.m. regarding the actual inventory count and disposition of Diazepam 5mg tablets that have been received in the hospital. The actual count in the pharmacy on 10/05/10 at 2:15 p.m. was 105 Diazepam 5mg tablets.

The perpetual inventory for the Diazepam 5mg tablets was reviewed with the pharmacist on 10/06/10 at 9:50 a.m. This review revealed that the perpetual inventory for this controlled drug was incomplete in that the documentation on the perpetual inventory report failed to indicate the disposition of the 5mg tablets of Diazepam.

The Chief Nursing Officer (S5) and the Compliance Officer (S3) were interviewed on 10/06/10 at 10:00 a.m. S5 and S3 indicated that they would assist the pharmacist (S8) in going through the nursing shift count reports in an effort to track the disposition of the Diazepam 5mg tablets received in the hospital. Upon review of the nursing shift count reports for the months of June 2010, July 2010, August 2010, September 2010, and October (to date) 2010, the Diazepam 5mg tablets were reconciled by use of the nursing documentation with the assistance of S3 and S5.

Review of "Pharmacy and Therapeutics Committee Meeting" minutes for the most recent two meetings were requested for review. This review revealed committee meetings dated 2/25/10 and 7/15/10. Review of the meeting minutes revealed no documentation to indicate that the hospital had identified that the perpetual inventory records for controlled drugs were incomplete and/or inaccurate.

Further review of the monthly Performance Improvement Pharmacy Report presented by Pharmacy on June 2010, August 2010 and September 2010 under the Compliance Item revealed the "... Narcotic count is correct/records are in order..."

An interview was held with S3 RN Compliance on 10/7/2010 at 10:15 am. She indicated QA had not identitifed the problem in pharmacy related to the lack of accurate documentation and accuracy in the perpetual inventory of controlled drugs. She further indicated there had not been any oversight in the pharmacy to ensure that the perpetual inventory was correct and current.