Failure to Secure and Document Controlled Substance Storage
Penalty
Summary
The facility failed to store and handle controlled medications in accordance with professional standards for one resident. Specifically, a resident with diagnoses including anxiety disorder, schizophrenia, and hallucinations had an active order for lorazepam, a controlled substance. Documentation showed that a quantity of lorazepam was delivered by the pharmacy and signed for by an LPN. However, staff interviews revealed confusion and lack of clear documentation regarding the receipt and storage of the medication. The medication was not properly accounted for, with staff unable to locate it after delivery, and there was no documentation confirming the transfer of the medication between staff members. Staff involved in the medication handoff provided conflicting accounts of the events, with one nurse stating she gave medications to the ADON, who then returned them, and another nurse stating she did not receive any narcotics or related documentation. The DON confirmed uncertainty about the whereabouts of the missing medication and acknowledged that the process for checking in and storing narcotics was not followed as required. The facility's policy required that controlled substances be signed in and stored in a locked compartment, but this was not consistently done, resulting in the medication being unaccounted for.