Improper Labeling and Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper labeling and storage of controlled substances for a resident with a diagnosis of malignant neoplasm of the bone and a pathological fracture of the left humerus. Upon admission, the resident brought a bottle of previously prescribed narcotics, which was taken by staff. However, the medication was not properly labeled or stored according to facility policy and professional standards. The bottle of oxycodone/acetaminophen (Percocet) brought from outside was kept in the medication cart and administered without a valid physician's order, and the controlled drug record (CDR) for this medication was handwritten, missing essential information such as dose, time, and route of administration. During a medication cart audit, a blister pack of discontinued oxycodone 10mg tablets was found stored with active controlled medications in the cart. The order for this medication had been stopped, but the medication remained accessible for over a month. A licensed nurse reported nearly making a medication error by almost administering the discontinued 10mg tablet instead of the currently ordered 5mg tablet. The nurse acknowledged that discontinued medications should not remain in the cart, as this increases the risk of administration errors. Interviews with staff, including the MDS coordinator, licensed nurses, and the DON, confirmed that the facility did not follow its own policies regarding the labeling and storage of controlled substances. The DON acknowledged that the Percocet brought from outside should not have been stored with active medications and that the CDR should not have been handwritten or missing required information. The facility's policy requires that all medications be labeled with the resident's name, medication name, dose, route, and other essential details, and that discontinued medications be removed or destroyed per pharmacy instructions.