Failure to Follow Physician Orders and Secure Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not following physician orders and facility policies regarding controlled substances. For one resident with low back pain and difficulty walking, the physician had discontinued Hydrocodone-Acetaminophen 10-325mg and ordered a lower dose of 5-325mg. However, staff continued to dispense and administer the 10-325mg tablets, with no documentation of tablet splitting or proper disposal of unused portions. The resident confirmed receiving the full 10-325mg tablet, and staff interviews revealed uncertainty about the administration process and a lack of adherence to the new order. In another instance, a bottle of Lorazepam Intensol, a controlled substance prescribed for anxiety, was found stored in an unlocked refrigerator in the medication room, contrary to facility policy requiring controlled substances to be kept in a locked container separate from non-controlled medications. Staff interviews indicated a misunderstanding of the storage requirements, with some believing the locked refrigerator was sufficient, while others acknowledged the need for an additional lock on the narcotic container. Additionally, the same bottle of Lorazepam Intensol for the second resident remained in the refrigerator six months after the medication had been discontinued by the physician. Staff failed to remove and properly dispose of the discontinued narcotic, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that discontinued controlled substances should be promptly removed and destroyed to prevent accidental administration.