Failure to Account for and Secure Discontinued Controlled Medication
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, specifically regarding the handling of a discontinued bottle of lorazepam for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and was receiving palliative care, had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety over a 14-day period. After the medication was discontinued, the bottle with the original prescription number could not be located during a review of medication records and physical inventory. During interviews and record reviews, it was found that the prescription number on the resident's Individual Count Sheet Record did not match the bottle present in the locked medication room. The Director of Nursing (DON) confirmed that the discontinued lorazepam bottle was not received for safekeeping and was not documented as destroyed according to facility policy. The DON also stated that the medication destruction log did not show that the missing bottle had been destroyed, and the bottle was ultimately unaccounted for. Facility policy requires that discontinued controlled substances be brought to the DON, locked for safekeeping, and destroyed in the presence of the DON and a pharmacist, with proper documentation. The failure of licensed nurses to follow these procedures resulted in the loss of accountability for the controlled medication, as the bottle of lorazepam was not properly secured or disposed of after discontinuation.