Controlled Substances Left Unsecured and Stolen
Penalty
Summary
A nurse (LVN A) failed to properly secure controlled substances after signing for a pharmacy delivery, leaving 80 tablets of various controlled medications unattended on the nursing station counter for several hours. The medications included narcotic pain medications, anti-seizure medications, anxiety medications, and sleeping aids. The medications were left out overnight while the nurse attended to a resident death and related responsibilities, and were not placed in the automated dispensing system or behind a double lock as required by facility policy and federal regulations. Multiple staff interviews confirmed that it was common practice for medications to be left unattended at the nursing station, and that on this occasion, the medications remained unsecured from the time of delivery in the evening until early the next morning. The medications were discovered missing when the nurse attempted to secure them at the end of her shift. Despite searches of the facility and drug testing of nursing and medication aide staff, the missing medications were never recovered, and the responsible nurse was terminated following the incident. Facility policies required that all controlled substances be immediately logged, counted, and stored in a locked container or automated dispensing system upon receipt, with access limited to authorized personnel. The nurse involved reported not having received training on medication delivery or stocking the automated dispensing system. The incident was confirmed through interviews with the administrator, DON, and other nursing staff, all of whom acknowledged that the medications were left unsecured and that this was a violation of both facility policy and regulatory requirements.