Failure to Secure Controlled Substances and Date Opened Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure controlled substances and to date medications as required by policy and regulation. Specifically, two of three medication storage refrigerators (ASSISI and Long-Term Care) were found unlocked while containing lorazepam, a Schedule IV controlled substance. In both cases, the narcotic lock boxes within the refrigerators were also left open or inoperable, and staff confirmed that these should have been locked and functional whenever controlled substances were present. Additionally, two of three medication carts (ASSISI and Long-Term 2) contained multiple opened but undated medications, including various ophthalmic drops and an insulin injector pen. Staff acknowledged that these medications were being administered to residents and should have been dated upon opening, in accordance with facility policy and manufacturer recommendations. The facility's own policies require that all medications, especially controlled substances, be stored securely and that medications be dated when opened to ensure their integrity and safe administration. During interviews, staff and the Director of Nursing Services confirmed that the observed practices did not meet these requirements. The deficiencies were identified through direct observation, staff interviews, and review of facility policies, with no mention of specific residents affected or adverse outcomes at the time of the survey.