Failure to Reconcile Controlled Medication Kits and Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to reconcile and account for six medication emergency kits (eKITs) containing controlled medications (CMs) in three medication rooms for the month of June 2025. During observations and interviews, it was found that none of the eKITs in Medication Room Stations 1, 2, and 3 had accountability logs for reconciliation of CM inventory at every shift change, as required by facility policy and federal and state regulations. Multiple licensed nurses confirmed that the eKITs were not reconciled at every shift, and the Director of Nursing (DON) acknowledged that the required accountability and reconciliation logs were not maintained for these kits during the specified period. Additionally, the facility did not have an available supply of tramadol, a controlled medication prescribed for moderate to severe pain, which affected a resident who was not administered the medication as ordered. On the morning of June 3, 2025, a licensed vocational nurse (LVN) was observed administering other medications to the resident but did not administer tramadol because it was not available in the medication cart or anywhere in the facility. The LVN instead administered Tylenol, which was only prescribed for lower pain levels, and acknowledged this as a medication error. The resident had reported a pain level of 5, which required tramadol according to the physician's order. Review of the resident's records indicated a history of spondylosis and cervical disc degeneration, with tramadol prescribed for pain levels between 5 and 10. The Medication Administration Record confirmed that tramadol was not administered as ordered. Facility policies reviewed indicated that medications, especially controlled substances, must be administered as prescribed and reconciled at each shift change, but these procedures were not followed, resulting in the deficiencies identified.