Failure to Periodically Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided to meet the needs of residents by not having an effective system in place to periodically reconcile all controlled substances. During interviews, the DON stated that while medications of discharged or deceased residents were stored in a locked box until destruction, there was no process for periodic reconciliation of controlled substances. The DON acknowledged the absence of such a system and recognized its importance in preventing missing drugs. The Registered Pharmacist also confirmed that there was no process for periodic reconciliation and emphasized the necessity of this practice to ensure all medications were properly accounted for. A review of the facility's policies and procedures revealed that they required periodic review and updating of controlled medication monitoring by the DON and consultant pharmacist, as well as regular reconciliation of controlled substance inventory to identify loss or diversion. However, these procedures were not being followed, as evidenced by the lack of a system for periodic reconciliation. This failure had the potential for diversion, mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.