Improper Storage and Handling of Controlled Substances
Penalty
Summary
During a narcotic count observation on the 500 hall medication cart, a Qualified Medication Aide (QMA) was found to have stored controlled substances, specifically Tramadol 50 mg tablets prescribed to a resident, in a manner inconsistent with facility policy and accepted professional standards. The QMA had removed the tablets from their original labeled dispensing container and placed them into multiple pill crusher sleeves, with each sleeve containing 20 half-tablets, some of which were stapled together. The QMA explained that this practice was sometimes done to make counting easier and that pills from different bottles of the same prescription were combined. The Executive Director confirmed that this practice was not in line with facility policy, which requires each drug to be kept in its labeled dispensing container and prohibits transferring drugs from one container to another.