Failure to Document Destruction of Controlled Medication
Penalty
Summary
A deficiency was identified when a facility failed to ensure the proper destruction and documentation of a controlled medication for a resident who was no longer present at the facility. The resident, who had diagnoses including anoxic brain damage and required a gastrostomy tube, was on a scheduled pain management regimen that included Tramadol, a controlled substance. Upon review of the resident's records, it was found that although 30 tablets of Tramadol were received and only six were administered, the required documentation for the destruction of the remaining 24 tablets was incomplete. Specifically, the section of the Individual Patient's Controlled Drug Record (IPCDR) for documenting the destruction—'destroyed by,' 'witnessed by,' and 'date'—was left blank. Interviews with facility staff confirmed that the destruction of controlled substances should be witnessed by two licensed staff members and properly documented, as outlined in the facility's own policy. The DON acknowledged that although the medication was placed in the drug destruction system, the required signatures and documentation were not completed due to being called away for a rapid response. The Assistant DON also confirmed that the declining inventory sheet should have been signed after destruction. This failure to follow established procedures resulted in a lack of accountability for the controlled medication as required by state and federal regulations.