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F0755
D

Failure to Properly Witness and Document Narcotic Medication Destruction

Gallatin, Tennessee Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its policy regarding the destruction of controlled substances for a resident who was prescribed Hydrocodone-Acetaminophen for pain management. According to the facility's policy, controlled substances must be destroyed or wasted in the presence of two licensed nurses, with proper documentation reflecting this process. However, medical record review showed that multiple entries for the wasting of the narcotic medication were documented by a single LPN, with the witness field left blank each time. The LPN wrote 'wasted' by hand but did not have a second licensed nurse present to witness the destruction, as required by policy. Interviews confirmed that the LPN responsible for administering and wasting the medication did not request another nurse to witness the process during the relevant shifts. The nurse working the same shift on an adjacent hallway stated she was not asked to witness any medication destruction. Both the Medical Director and the Administrator confirmed that the facility's policy was not followed, as the destruction of the narcotic medication was not witnessed by a second licensed nurse.

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