Failure to Secure and Timely Dispose of Controlled Substances
Penalty
Summary
The facility failed to implement procedures to ensure accurate controlled drug records and timely disposition of resident medications, specifically for one resident who was discharged to the hospital with no anticipation of return. Upon discharge, two controlled substances, Tramadol and Diazepam, were secured in the DON's office, with 39 Tramadol tablets and 38 Diazepam tablets documented as placed there. The controlled substance log showed that these medications were not destroyed until 20 days later, indicating they were stored in the DON's office for an extended period before proper disposition. Observation revealed that the locker designated for controlled substance storage in the DON's office had only one key, which was kept by the DON, but staff had access to the office itself, creating an opportunity for unauthorized access to the medications. The DON confirmed that when she was unavailable, staff placed controlled medications in her office, but did not have access to the locker. During the DON's absence, the medications remained unsecured. The facility was unable to provide a narcotic log for the medications stored in the locker and had no plan in place for proper accounting of narcotics awaiting disposition. Interviews with the DON and NHA confirmed the lack of documentation and procedures to ensure accurate controlled drug records and timely medication disposition.