Controlled Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and proper storage of narcotic medications, affecting four out of five residents reviewed for controlled medications. On April 1, 2025, discrepancies were noted during medication counts with various nurses. For instance, a nurse failed to sign out a tablet of Tramadol administered to a resident, resulting in a discrepancy between the actual count and the record. Another nurse was found to have taped over a broken seal of a Tramadol blister pack, which is against the facility's policy. Further observations revealed that a blister pack of Lorazepam had a torn tablet, and a nurse failed to document the administration of Methylphenidate, leading to a discrepancy in the count. The Director of Nursing confirmed that nurses are required to sign out narcotic medications immediately after administration and that damaged packaging should not be taped over but discarded with a witness. The facility's policy mandates accurate accountability and documentation of controlled substances, which was not adhered to in these instances.