Failure to Accurately Reconcile and Dispose of Controlled Medication
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed clonazepam for anxiety. On the observed date, a registered nurse (RN) removed a tablet of clonazepam from the medication card, crushed it, and prepared it for administration via the resident's gastrostomy tube. The RN then signed off the administration in the narcotic log. However, the narcotic record indicated there should have been two tablets remaining, but only one was present. The RN explained that she had disposed of a tablet after recalling that a state surveyor wanted to observe the administration, but did so without obtaining a witness, as required by facility policy. The RN admitted she was unfamiliar with the facility's policy, having only recently started working there, and did not secure a witness during the disposal process. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living, and received medications via a feeding tube. Facility policy and interviews with the Director of Nursing (DON) and Administrator confirmed that a witness is required when disposing of controlled medications, and failure to do so could lead to discrepancies in drug accountability. The lack of a witness and improper reconciliation of the narcotic log resulted in an inability to accurately account for all controlled drugs, as required by federal and state regulations.