Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper receipt, accountability, reconciliation, secure storage, and removal from active inventory of controlled substances for multiple residents. Surveyors observed that controlled drugs, including Lorazepam, Fentanyl patches, Methadone, Hydrocodone/Acetaminophen, Morphine Sulfate, and Alprazolam, were found in an unlocked cabinet and refrigerator in the medication room, some of which were labeled for residents who had been discharged or had expired. Documentation such as Individual Patient Controlled Substance Administration Records (IPCSAR) was missing or inaccurate for these medications, and the drugs were not being included in shift-to-shift controlled substance counts. Staff, including the Unit Manager and DON, were unaware of the presence of these medications and could not provide proper records or explain the discrepancies. Further deficiencies were identified in the management of controlled drugs on medication carts. For one resident, the IPCSAR for Nayzilam spray indicated a remaining balance that could not be accounted for, and the receiving nurse had not properly documented the date or amount received. Additionally, two IPCSARs for Diazepam gel did not accurately correspond to the remaining inventory, and a return medication form was incorrectly attached to a controlled drug that should not have been returned to the pharmacy. The DON acknowledged these inaccuracies and the lack of proper reconciliation and removal from active inventory for discontinued medications. Another deficiency involved the documentation and destruction of a Buprenorphine patch. The Controlled Substance Administration Record for the patch showed that the same patch was both applied and removed on the same date and time, which did not align with the physician's order for weekly application. The nurse involved admitted to not obtaining the required second signature for the destruction of the old patch, and the DON confirmed that proper documentation and witness signatures were not present at the time of wastage. These findings collectively demonstrate a failure to comply with facility policies and regulatory requirements for the handling, storage, documentation, and destruction of controlled substances.