Failure to Properly Store and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper storage and reconciliation of controlled substances, specifically Ativan vials, in the medication room backup supply. During an observation, it was found that the refrigerator containing the Ativan vials was unlocked, and the locked plastic box inside was not permanently affixed to the refrigerator. The number of Ativan vials inside the box was unclear, as they were stored in blue plastic bags and not visible. Nursing staff were unable to immediately access the key to the box, and there was confusion regarding the reconciliation process for these vials. The narcotic reconciliation booklet did not contain any documentation for the Ativan vials stored in the medication room refrigerator. Interviews with nursing staff and the DON revealed inconsistent practices and a lack of clear documentation regarding the reconciliation of the Ativan vials. The pharmacy consultant was reported to reconcile backup medications every other week, but the facility was unable to provide documentation to confirm that the Ativan vials had been reconciled. Additionally, the facility's policy required controlled substances to be monitored and reconciled to identify loss or diversion, but no evidence was provided to show that this was being done for the Ativan vials in question.
Plan Of Correction
The facility provides safe narcotic storage and reconciliation. 1. The emergency back-up Ativan was added to the downstairs medication cart narcotic perpetual inventory to reconcile every shift with narcotic counts; the secure box was secured to the refrigerator to prevent removal of the box. Pharmacy verified on 3/11/25 that the backup Ativan stock was correct. 2. Each medication cart was audited by the DON on 3/17/25 to ensure narcotic storage and reconciliation was complete. 3. Licensed nursing staff were re-educated on 3/26/25 by the DON or designee, regarding survey results including but not limited to the safe storage and reconciliation of refrigerated controlled medications. 4. The DON or designee will conduct weekly audits of Performance Monitoring related to safe narcotic storage and reconciliation weekly x 4, then monthly. Any identified areas of concern will be addressed and immediately corrected. Results of the audits will be taken to the QAPI Committee for review and recommendation and for determination of continued monitoring.