Deficiencies in Emergency Medication Documentation and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its policies and procedures, as evidenced by several deficiencies related to emergency medication management and controlled substance documentation. During inspections of the medication rooms and carts, it was observed that emergency kits (E-Kits) had been opened and resealed with red color-coded locks, but there was no documentation in the Emergency Kit Log regarding which medications were removed or the dates of removal. Multiple white slips in the narcotic E-Kit indicated repeated access, yet the required log entries were missing. The Assistant Director of Nursing (ADON) confirmed that licensed nurses were expected to record all medication removals in the log and notify the pharmacy for kit replacement, as outlined in the facility's policy. Additionally, an expired insulin E-Kit from a previous pharmacy provider was found in the refrigerator, and the ADON acknowledged it should have been removed or destroyed after the pharmacy change, in accordance with policy requirements for handling discontinued or outdated medications. Further, a discrepancy was identified in the controlled drug record for a resident receiving narcotic pain medication. The on-hand count of Percocet tablets did not match the documented record, with one less tablet present than recorded. The licensed nurse attributed the discrepancy to a missed documentation by the night nurse, who had administered the medication but failed to record it. The ADON stated that both outgoing and incoming staff were expected to reconcile and sign off on narcotic counts at each shift change, as per facility policy. These findings demonstrate lapses in medication documentation, storage, and accountability.