Failure to Properly Store and Destroy Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly stored and destroyed according to policy for two residents. In one instance, a resident's Morphine Sulfate was found stored in the bottom drawer of a medication cart, which is not a locked compartment designated for controlled substances. The medication was supposed to be kept in a locked controlled medication compartment, but was instead located among inhalers. The controlled drug record indicated that only one dose had been signed out, and staff interviews confirmed that the medication was misplaced and not secured as required. Additionally, the facility's controlled substance shift change count sheets were incomplete, with missing entries for the relevant period, and the Director of Nursing confirmed that the required documentation was not fully available. In another case, a resident's Norco prescription had been discontinued, but the medication card with 19 tablets remained in the locked compartment of the medication cart. The order for Norco had been discontinued several days prior, yet the medication was not removed or destroyed as per facility policy. The Director of Nursing verified that the medication should have been pulled and destroyed after discontinuation, but this was not done, resulting in the continued presence of discontinued controlled medication in the facility.