Failure to Secure Controlled Substances in Medication Room
Penalty
Summary
The facility failed to ensure that medications with the potential for abuse, specifically controlled substances, were secured in a locked, permanently affixed compartment at all times in one of the four medication rooms on the first floor. This deficiency was identified during an observation on April 9, 2025, at 12:31 p.m., when it was noted that the first floor medication room refrigerator contained 12 vials and two bottles of a Schedule IV anti-anxiety medication, lorazepam, which were not secured in a locked compartment within the refrigerator. The facility's policy, last reviewed on March 31, 2025, required that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 be separately locked in permanently affixed compartments, including those stored in refrigerators. During an interview on the same day at 10:20 a.m., the Director of Nursing confirmed that the controlled medications should have been locked within a separate, locked, and permanently affixed compartment of the refrigerator, indicating a failure to adhere to the facility's policy and regulatory requirements.
Plan Of Correction
Part 1. The first floor medical room refrigerator was repaired to have a secured lock. Part 2. Facility medical room refrigerators were inspected to ensure each refrigerator had a functioning locked compartment. Part 3. Staff education completed regarding the locking of the refrigerated narcotic medications. Part 4. To prevent recurrence, unit med room refrigerators will be audited to ensure the locking mechanism is functioning properly. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.