Failure to Timely Destroy Discontinued Controlled Substances
Penalty
Summary
The facility failed to properly destroy discontinued controlled substances for two residents, as required by policy and regulation. For one resident with osteoporosis, anxiety disorder, and delirium, an order for lorazepam was discontinued, but 28 tablets remained in the controlled substances drawer. For another resident with Alzheimer's disease, depression, and anxiety, an order for lorazepam was also discontinued, yet 14 tablets remained in the drawer. Both residents had intact cognition according to their most recent assessments, though one had intermittent confusion and sundowning noted in the care plan. During an observation, an LPN removed all bubble packages from the double-locked controlled substances drawer and found the discontinued lorazepam tablets for both residents still present. Interviews with nursing staff and the DON confirmed that discontinued controlled substances should be destroyed or returned to the pharmacy immediately, and that the presence of these medications indicated a failure to follow this protocol. The facility's policy required waste or disposal of controlled medications to be done with a witness and proper documentation, which was not followed in these cases.