mgr-u mm I. #24 FY2018 REPORT OF THEFT OR LOSS OF CONTROLLED SUBSTANCES Federal regulations require registrants to submit a detailed report of any theft or loss of controlled substances to the Drug Enforcement 3MB APPROVAL Administration. This form is ?lled out consistent with your entries in the ?elds on the previous pages. You should print this form and save 110]? 000' . it for your records. This form was submitted through the Internet, please do NOT send a cepy to DEA. 9:30:20 1 -xplres . 2. Phone No. When Amendment Key Date 1. Name and Address of Registrant Submitted Submitted MEDICAL CITY PLANO . 72 4 3901 WEST 15TH STREET 08f: PHARMACY DEPARTMENT 10 58'31 PLANO . TX 75075 9725191181 3. DEA Registration Number I 4. Date of Theft 1 Loss I S. Registrant's Principal Business 305733399 I Aug 2017 Amendment a 6. Registrant's County I Egg? Reported to I 8. Name and Phone of Police Dept. COLLIN I No KiOlNLutgisb?er of Thefts I Losses Registrant Has Experienced in Past 24 I 10. Type of Thel?t I Loss 7 I Employee Pilt?erage ll. Killed I Injured Due to Armed Robbery (Purchase) Value ofCuntrolled I 1?3..Pharmaceuticals or Merchandise uhstances Taken? I szrmo I No 14. The following applies when Type of Theft! Loss (Box 10} is "Lost In Transit": A. Name of Common Carrier I B. Name of Consignce I C. Consignee's DEA Registration Number D. Did the Customer Receive the I E. Was Carton Tempered With? I F. Theft or Loss From This Same Carrier Carton? In the Past 15. What identifying marks. symbols or price codes were on the labels of these containers that would assist in identifying them? Midazolam Zing/2m! 00641?6052-25; Midazolam Singa?Sml 00641-6059-10; Dcmerol 50mg syringe 00409-1178-30; Hydromorphone 2mg 00409?3365-01; Fenlanyl 250mcg 5m 00409-9093-35; Fentanyl 100 2m! 00641-6027-25 16. Numbers of Of?cial Controlled Substances Order Forms (DEA-222) .J What security measures have been taken to prevent future theft loss? i: Eliminating Pyxis overrides. installing cameras, adding co-witness. l; 18. Comments . n. - l9. Filer Name. Title. Phone: 7 .14 Chad Friece. Director of Pharmacy Services (214)473-2597 The following is a list of the coutrolled substances that were lost or stolen: NDC Number Trade Name Dosage Str. Quantity 00409117830 DEMEROL 50 MGIML CARPUJECT 50 1 ML 00409336501 HYDROMORPHONE 2 MGEML VIAL 2 MGEML 4 ML 00409909335 FENTANYL 0.05 AMPUL 50 1,110 ML 00641602725 FENTANYL 100 ML VIAL 50 34 ML 00641605725 MIDAZOLAM HCL 2 ML VIAL 2 ML (1 8 ML 00641605910 MIDAZOLAM HCL ML VIAL 5 ML (1 600 ML I Print Close do REPORT OF THEFT OR LOSS OF CONTROLLED SUBSTANCES Federal regu'atiens require registrants to subunit a detailed repnrt nfany theft or loss ofcontrolled substances to the Drug Enforcement 0MB APPROVAL Administration. This farm is ?lled out consistent with your entries in the ?elds 0n the previous pages You should print this form and save No. . it for your reCters. This furm was submitted through the Internet. please do NOT send a copy to DEA. Expires . . 2. Phone No. When Amendment Key Date 1. Name and Address of Registrant Submitted Submitted MEDICAL CITY PLANO 3901 \vesr 15TH STREET Engage/twice PHARMACY DEPARTMENT 09?44?06 PLANO . TX 75075 9725191181 3. DEA Registration Number 4. Date of Theft 1' Loss i 5. Registrant's Principal Business BCST38399 1 Sep 06, 2013' Amendment :5 0 HOSPITAL-CLINIC 6. Registrant's County I 33:23.! Reported to 8. Name and Phone of Police Dept. coLLtN No ofThefts Losses Registrant Has Experienced in Past 24 10. Type of Theft J. Loss 8 I Employee Pilfet'rtge il. Killed Injured Due to Armed Robbery (Purchase) Value oI?Controlled 13. Pharmaceuticals or Merchandise ubstances Taken? 51.00 No 14. The following applies hen Type of Theft! Loss (Box 10} is "Lost In Transit": A. Name of Common Carrier I B. Name of Consignee 1 C. Consignee's DEA Registration Number 12?, :3 a D. Did the Customer Receive the E. Was Carton Tampered With? F. Theft or Loss From This Same?'rier Carton? the Past 1 a r" 15. ?hat identifying marks. symbols or price codes were on the labels of these containers that would assist in identifying them :3 Hydrocodone Smgr?aeetazninOphen 325mg tablet (in: 1} 9. 16. Numbers of Of?cial Controlled Substances Order Forms (DEA-222) 5 A 17. hat security measures hat been taken to prevent future theft loss? More consistent auditing ofdatly Pyxis variance report 18. Comments Filer Name. Title, Phone: Chad Friece, Director of Pharmacy Servrces f2l4i473-T-?5W The following is a list of the controlled substances that uere lost or stolen: NDC Quantity Trade Name Dosa Str. Number Lost/ Stolen HYDROCODONE-ACETAMINOPHEN 7.5?325 7.5 MG-325 68084086301 TAB MG 4 EA Close deadiversion usdo; REPORT OF THEFT OR LOSS OF CONTROLLED SUBSTANCES Federal regu'atiens require registrants to subunit a detailed repnrt nfany theft or loss ofcontrolled substances to the Drug Enforcement 0MB APPROVAL Administration. This farm is ?lled out consistent with your entries in the ?elds 0n the previous pages You should print this form and save No. . it for your reCters. This furm was submitted through the Internet. please do NOT send a copy to DEA. Expires . . 2. Phone No. When Amendment Key Date 1. Name and Address of Registrant Submitted Submitted MEDICAL CITY PLANO 3901 \vesr 15TH STREET Engage/twice PHARMACY DEPARTMENT 09?44?06 PLANO . TX 75075 9725191181 3. DEA Registration Number 4. Date of Theft 1' Loss i 5. Registrant's Principal Business BCST38399 1 Sep 06, 2013' Amendment :5 0 HOSPITAL-CLINIC 6. Registrant's County I 33:23.! Reported to 8. Name and Phone of Police Dept. coLLtN No ofThefts Losses Registrant Has Experienced in Past 24 10. Type of Theft J. Loss 8 I Employee Pilfet'rtge il. Killed Injured Due to Armed Robbery (Purchase) Value oI?Controlled 13. Pharmaceuticals or Merchandise ubstances Taken? 51.00 No 14. The following applies hen Type of Theft! Loss (Box 10} is "Lost In Transit": A. Name of Common Carrier I B. Name of Consignee 1 C. Consignee's DEA Registration Number 12?, :3 a D. Did the Customer Receive the E. Was Carton Tampered With? F. Theft or Loss From This Same?'rier Carton? the Past 1 a r" 15. ?hat identifying marks. symbols or price codes were on the labels of these containers that would assist in identifying them :3 Hydrocodone Smgr?aeetazninOphen 325mg tablet (in: 1} 9. 16. Numbers of Of?cial Controlled Substances Order Forms (DEA-222) 5 A 17. hat security measures hat been taken to prevent future theft loss? More consistent auditing ofdatly Pyxis variance report 18. Comments Filer Name. Title, Phone: Chad Friece, Director of Pharmacy Servrces f2l4i473-T-?5W The following is a list of the controlled substances that uere lost or stolen: NDC Quantity Trade Name Dosa Str. Number Lost/ Stolen HYDROCODONE-ACETAMINOPHEN 7.5?325 7.5 MG-325 68084086301 TAB MG 4 EA Close deadiversion usdo;