Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper pharmacy services for 11 residents by not documenting destruction logs for discontinued controlled medications and not reconciling controlled drug records when original narcotic sheets went missing. During an observation and record review, it was found that 11 controlled medications stored in the DON's office lacked destruction logs, and the medications were not scanned or recorded into the pharmacy website upon receipt from the nurses. The DON confirmed these omissions and acknowledged that the controlled drugs in the locked cabinet were not properly accounted for at the time of transfer from nursing staff. Additionally, the original controlled drug sheets for medication cart A2 went missing and were replaced with photocopied handwritten narcotic sheets. When the original sheets were later found, no reconciliation was performed to check for discrepancies. The DON verified that the reconciliation process was not completed, and the facility's consultant pharmacist confirmed that both a destruction log and reconciliation between two nurses were required by facility policy. The facility's policy also stated that all controlled substances must be fully accounted for and any discrepancies resolved by the end of the shift.