Failure to Accurately Account for and Store Controlled Medications
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and did not maintain proper storage of narcotic medications in sealed packaging. During a medication count with a nurse, it was observed that one resident's blister pack of Tramadol had broken seals on two tablets. For three other residents, the number of controlled medication tablets remaining in their blister packs did not match the amounts recorded on the controlled drug receipt/record/disposition forms. In each case, the nurse stated that the medication had been administered but not yet signed out on the required documentation. The facility's policy requires that controlled medications be documented in the Medication Administration Record and signed out on the controlled drug record immediately after administration. Additionally, any controlled medication with a broken seal should be disposed of with a witness to prevent discrepancies or diversion. These requirements were not followed, resulting in discrepancies between the physical count of medications and the documentation, as well as improper storage of controlled substances.