Failure to Maintain Accurate Records for Controlled Drug Destruction
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate account of medication destruction for five sampled residents. Facility policy required that outdated or unused medications be returned to the contracted pharmacy for destruction by the pharmacist, and the Pharmacy Services Agreement specified compliance with federal and state regulations. However, review of medical records and destruction logs for multiple residents revealed that controlled substances, including Alprazolam, Hydrocodone-Acetaminophen, Morphine Sulfate, Tramadol, and Lorazepam, were documented as destroyed by the pharmacist and the DON, with all medications reportedly destroyed at the local police department. Interviews with facility staff, including the pharmacist, administrator, and DON, revealed that the process involved the pharmacist collecting the medications, signing them off on the resident record, and transporting them in a locked suitcase to the police department, where they were deposited in a sealed box in the lobby. No receipt or documentation was provided by the police department to confirm the destruction of the medications, and no logs were kept by the police department regarding the drop-off or destruction of the drugs. The facility's records only showed that the medications were sent back to the pharmacist, with no further proof of destruction. The lack of a detailed and verifiable record of the destruction of controlled substances meant that the facility could not accurately account for the disposition of these medications. This deficiency was identified for all five sampled residents reviewed for drug destruction, each of whom had controlled substances documented for destruction without sufficient supporting records to confirm the process was completed in accordance with regulatory requirements.