Deficient Controlled Substance Documentation and Storage
Penalty
Summary
Surveyors found that the facility failed to ensure controlled medications were administered and documented according to professional standards for multiple residents. For several residents receiving narcotic medications, there were discrepancies between the narcotic sign-out sheets and the Medication Administration Records (MARs). In some cases, doses were signed out on the narcotic sheets without corresponding documentation in the MAR, and in other instances, the MAR indicated administration without a matching entry on the narcotic sheet. Additionally, incorrect doses were documented, and initial volumes of medication were not always properly recorded when narcotics were dispensed and stored in the medication cart. Further review revealed inconsistencies in the counting and documentation of remaining narcotic volumes, with some staff recording increases in volume that were not possible, and explanations provided by staff and the Director of Nursing (DON) indicated a lack of clarity and adherence to proper procedures. In one case, a narcotic spill was documented by a nurse without a second licensed nurse verifying and signing off on the incident, contrary to facility policy. The DON acknowledged that the expected process was not followed and that discrepancies persisted despite previous education and audits. Additionally, a controlled substance (Lorazepam) was observed stored in a medication room refrigerator without being double locked, as required. Staff, including the RN and DON, were either unaware or unsure of the double-lock requirement for this medication. These findings demonstrate a pattern of inadequate pharmaceutical services and failure to meet regulatory requirements for the handling, documentation, and storage of controlled substances.