Deficient Controlled Drug Reconciliation and Removal of Discontinued Medications
Penalty
Summary
The facility failed to maintain an accurate and effective system for the reconciliation of controlled drugs and the timely removal of discontinued medications from medication carts. For one resident, there was a discrepancy between the Controlled Medication Utilization Record and the Medication Administration Record (MAR) for alprazolam 0.25 mg, with documentation showing the medication was removed from the med cart on two occasions, but no corresponding administration was recorded on the MAR. The LPN interviewed confirmed that the process is to document removal on the Controlled Medication Record and administration on the MAR, but this was not done for the identified dates. For another resident, alprazolam 0.25 mg was discontinued per physician's order, but the medication was not promptly removed from the med cart. The DON stated that discontinued medications should be removed within a couple of days and that the night shift nurse is responsible for checking the cart nightly. However, the medication remained in the cart beyond the discontinuation date, indicating a lapse in the facility's process for handling discontinued controlled substances.