Failure to Secure and Account for Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate acquiring, receiving, dispensing, and administering of controlled substances. Specifically, a nurse (LVN A) signed for a delivery of 80 controlled substance tablets, including narcotic pain medications, anti-seizure medications, anxiety medications, and sleeping medications. Instead of immediately logging these medications into the automated dispensing system as required by facility policy, LVN A left the medications unattended on the nursing station counter for several hours while attending to other duties, including managing a resident death. The medications remained unsecured and were later reported missing. Multiple staff interviews confirmed that it was common practice to leave medications unattended at the nursing station, and LVN A stated she had not received training on medication delivery or stocking the automated dispensing system. The missing medications were never located despite searches of the facility, and the incident was reported to facility management. The facility's policies required that controlled substances be counted upon delivery, logged into the automated dispensing system, and stored securely, but these procedures were not followed in this instance. The investigation revealed that the lack of proper documentation and secure storage led to the loss of the controlled substances. Staff did not conduct a search of resident rooms or personal belongings, nor did they assess residents for potential ingestion of the missing medications. The facility's failure to maintain an accurate inventory and secure storage of controlled substances resulted in the inability to reconcile the missing drugs and prevent drug diversion.