Failure to Secure and Account for Controlled Medications
Penalty
Summary
Surveyors identified several deficiencies related to the management of controlled medications. During an observation of the medication storage area, a nurse accessed a refrigerator containing controlled substances without a lock, despite the presence of Lorazepam for a resident whose medication order had already been completed. The nurse acknowledged that the refrigerator should have been locked due to the presence of controlled medications and found the lock on the floor, indicating it was not in use. Additionally, the completed Lorazepam medication, which should have been returned to the pharmacy after the order ended, was still present in the facility. Further review of medication administration records and interviews revealed that the facility failed to ensure proper documentation on the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. Specifically, there were missing signatures from outgoing nurses on two separate dates, which was confirmed by staff. The expectation, as stated by facility leadership, is that both incoming and outgoing nurses count and sign for controlled medications at each shift change to ensure accountability and accurate record-keeping. The residents affected by these deficiencies included individuals with diagnoses such as osteoarthritis, hypertension, seizure history, neuralgia, hemiplegia, low back pain, post-traumatic stress disorder, and sleep disorder. The facility’s policies and job descriptions require that controlled substances be double locked, properly disposed of or returned when no longer needed, and that accurate shift-to-shift counts and documentation be maintained. These requirements were not met, as evidenced by the unsecured storage, retention of completed medications, and incomplete shift count records.