Failure to Timely Return and Account for Controlled Medications
Penalty
Summary
The facility failed to maintain effective systems for the timely return of controlled medications to the pharmacy across all four medication carts. Documentation revealed that numerous cards and containers of controlled substances, including those belonging to discharged residents, remained on the medication carts instead of being promptly returned. Inventory count sheets showed that large numbers of controlled medication cards were removed from the carts on specific shifts, but some empty cards were not properly documented, and there was a lack of clarity regarding which residents and medications were involved. Staff interviews confirmed that nurses were required to count excessive numbers of controlled medications each shift, many of which should have already been returned, increasing the risk of errors in accounting for these substances. Further interviews indicated that the former DON was unable to manage the return of controlled medications due to overwhelming job responsibilities, and the facility had been without effective nursing leadership. The consultant pharmacist was not aware of the facility's exact procedures for handling discontinued or expired controlled medications, but stated that such medications should be removed from carts, double-locked, and returned to the pharmacy at the next available opportunity. The Regional Clinical Director confirmed that the expected process was not being followed, as discontinued controlled medications were left on the carts rather than secured and returned, and inventory count sheets were not consistently or accurately completed and verified by two nurses.