Failure to Accurately Account for and Secure Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications for six out of seven residents in one of two inspected medication carts. Nurses did not document the removal and administration of controlled substances on the Controlled Medication Count Sheet (CMCS) at the time the medications were administered. For example, a nurse counted fewer tablets in the prescription bottle than recorded on the CMCS for a resident prescribed Amphetamine/Dextroamphetamine, and only documented the administration several hours after the scheduled time, expressing uncertainty about whether the medication had been given. Similar discrepancies were found for other residents, where the number of tablets in medication cards did not match the CMCS, and the nurse admitted to not documenting doses at the time of administration. Additionally, the facility failed to remove and securely store controlled medications belonging to residents who were no longer present in the facility. Medications for a resident who had been transferred to the hospital and another who had expired were found mixed with current residents' medications in the medication cart. The Director of Nursing (DON) confirmed that medications for residents who are no longer in the facility should be removed from the cart and stored securely until destruction, as per facility policy. The facility's policies require that licensed nurses immediately document the date, time, amount administered, and their signature on the accountability record when a controlled medication is removed from the supply, and to store discontinued or leftover controlled medications in a double-locked area until destroyed. These procedures were not followed, as evidenced by the discrepancies in medication counts, lack of timely documentation, and improper storage of medications for discharged or deceased residents.