Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a review of one medication cart. The narcotic accountability record for the cart, covering a period from 11/1/25 to 11/19/25, was found to have 16 missing licensed nurse signatures. Additionally, the narcotic count sheet for a resident's Butrans transdermal 7.5mg patch indicated that 10 patches were available, but only 2 patches were physically present in the narcotic box. Upon further review with the Director of Nursing (DON), it was determined that only 4 patches had been delivered, and 2 patches had not been signed out on the narcotic count sheet. Staff interviews revealed that nurses were expected to sign the narcotic accept/release sheet when accepting or releasing the medication cart, but this was not consistently done. The MDS coordinator was unable to explain the discrepancy in the count of the Butrans patches and stated he would investigate further. The DON confirmed that a missing Butrans patch had been signed out on the Medication Administration Record (MAR) but not on the narcotic count sheet, as required by facility policy.