Observations:
Based on tour of the facility and employee interview(EMP), it was determined that the facility failed to implement proper storage and dispensing of medications.
Findings include:
A tour conducted on March 27, 2025, at 11:00 AM, revealed concerns related to management of drugs in the facility.
Observation of the controlled substance cabinet revealed that Vicodin was being stored outside of its original packaging, in small plastic boxes to facilitate easier visualization, per EMP1.
This storage did not include the original manufacturers label, expiration, or strength.
Observation of the non-controlled medication storage system revealed a cabinet which contained various medications. When asked about the process for ordering, and maintaining availability of these drugs, EMP1 replied that they do a visual check to see if anything looks like it is "running low". When asked how medication is dispensed for patient administration, EMP1 replied that the nurse will remove it. The surveyor then asked EMP1 how they monitor the stock of drugs in the cabinet. EMP1 replied that they do not utilize a daily or weekly count system in maintaining the stock of non-controlled substances, but that they periodically check for product expiration.
The above was confirmed by EMP1 on March 28, 2025, at approximately 12:00 PM.
| | Plan of Correction - To be completed: 04/08/2025
It is the intended preference of Delmont Surgery Center to purchase controlled substances in a unit dose packaging supply. However, at times the Center's main distributor, Curascript, has been unable to provide controlled substances in unit dose packaging due to backorders. In this instance the Center had to purchase controlled substances in a bottle form with a quantity of 100 and stored them in a plastic pill dispensing container that was labeled with the medication name, lot number and expiration date. This has been stored in a triple locked cabinet in which by policy the inventory of controlled substances is counted by two licensed professionals upon opening and closing of the Center.
One of these substances, Vicodin, was stored in a plastic container without the strength labeled on the container. The strength is noted in the narcotic log book. On 4-7-2025 the Nurse Administrator created a label to note the strength of the medication (Hydrocodone 7.5 mg/Acetaminophen 325 mg) was affixed it to each container. Again, best practice is to purchase controlled narcotics in unit dose packaging in their respective boxes; that is the first goal when purchasing controlled medications. If unable to secure this type of packaging when ordering controlled narcotics, the Center will retain original packaging and store with plastic containers in addition to clearly labeling each medication with the strength, lot number and expiration date.
In regards to non-controlled medications that are stored at the Center, a weekly inventory is being completed every Monday by the PACU nurses. Any inventory that is low (under a quantity of five) will be relayed verbally to the DON whom is responsible for ordering medications and will place an order to fulfill the low count with the Center's weekly order.
In addition, at the beginning of every month, within the first week, a monthly inventory of all mediations and crash carts are being completed by nurses, taking note of the quantity and expiration dates of each medication. Logs are completed and then given to the Nurse Administrator and is kept on file in the Life Safety Manual. Any expired medications are discarded and then relayed to the DON to order a replacement.
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