Failure to Follow Proper Procedures for Wasting and Documenting Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and accurate handling of controlled substances for its residents. Specifically, on one medication cart, a nurse documented the wasting of a Tramadol tablet for a resident but did not obtain the required witness signature, as mandated by facility policy. The policy requires that the destruction of controlled substances be witnessed and documented by at least two staff members. The LPN involved confirmed that the witness signature was missing for the wasted medication. Additionally, another incident involved a resident's Hydrocodone/APAP tablet, which was removed from its blister pack but not administered. Instead of properly wasting the tablet according to protocol, the nurse taped the tablet back into the packaging, which is not permitted by facility policy. The DON confirmed that nurses are aware of the correct procedures, which include never returning a tablet to the packaging after it has been opened and always having two nurses witness and document the destruction of controlled substances. These failures resulted in non-compliance with both facility policy and regulatory requirements for the handling and documentation of controlled substances.