Failure to Maintain Adequate Medication Availability and Secure Dispensing Practices
Penalty
Summary
The facility failed to ensure that medications, specifically controlled substances, were available to meet the needs of each resident. Documentation review revealed multiple instances where controlled medications such as Lorazepam, Oxycodone, and Tramadol were borrowed from one resident's supply to administer to another resident. These borrowings were recorded on Controlled Substance Disposition Records, with some entries lacking clear identification of the recipient. Interviews with nursing staff confirmed that when a medication was needed immediately and not available, the nursing supervisor would obtain the medication from another resident's supply. Additionally, it was noted that not all shifts had staff authorized to access the after-hours automated medication dispensing system (Pyxis), which further contributed to the practice of borrowing medications. The Director of Nursing Services (DNS) acknowledged awareness of this practice and identified limited access to the Pyxis system and late-day admissions as contributing factors. The facility's pharmacy consultant also observed and reported the borrowing of controlled medications during routine inspections, emphasizing that first doses should not be obtained from other residents. Facility policy requires only authorized and trained nursing personnel to access the automated medication dispensing system, but gaps in staff authorization and access were identified as root causes for the deficiency.