Failure to Ensure Timely Controlled Substance Discrepancy Resolution and Medication Labeling
Penalty
Summary
The facility failed to ensure proper management and accountability of controlled medications, as evidenced by an unresolved discrepancy in the electronic medication cabinet. An alert indicating a discrepancy was present on the medication cabinet for at least four days, and neither agency staff nor regular nursing supervisors had the access or authority to resolve it. The Director of Nursing Services (DNS) was ultimately responsible for investigating and resolving such discrepancies but had not accessed the cabinet or performed any inventory of controlled substances for a period of 20 days. The discrepancy, related to the count of Oxycodone 10 mg, was only resolved after surveyor intervention, revealing a lack of timely oversight and investigation as required by facility policy. Additionally, the facility failed to ensure that medications intended for individual resident use were properly labeled and dated. During an observation of a medication cart, a bottle of saline nasal spray was found without any resident identifying information, and the nurse present could not confirm to whom the medication belonged. The facility's policy required all multi-dose over-the-counter medications to be labeled and dated, but this was not followed, and the medication was subsequently disposed of after the deficiency was identified. The facility also did not consistently complete required controlled drug/change of shift audits. Review of audit forms for multiple medication carts over several months revealed numerous missing shift-to-shift controlled substance counts, with many forms either incomplete or not provided at all. Facility policy mandated that licensed nurses from both outgoing and incoming shifts jointly conduct and document these counts, but this process was not reliably followed, resulting in gaps in documentation and accountability for controlled substances.