Failure to Secure and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of controlled medications for one resident, resulting in a deficiency related to the handling of controlled substances. On a specific date, an LPN received and signed for a delivery of Lorazepam and Morphine from hospice, with the transaction documented on a receipt. The LPN reported that the medication delivery occurred during a shift change and that the count verification was completed with the incoming nurse. However, the LPN later stated they were unsure when the Lorazepam went missing, as they were assigned to a different hall after a few days. It was also revealed that both nurses and medication aides had access to the medication carts, and that approximately 10-15 staff members had access to the cart containing the controlled substances since the date of delivery. Further review showed that there was no physician order for Lorazepam for the resident prior to a certain date, despite the medication being added to the shift count. Additionally, the medication administration record (MAR) sheet for the Lorazepam was missing, and staff were not consistently or completely filling out the required shift change controlled substance inventory count sheets. The facility's policy required a count of controlled substances at each shift change, but documentation was incomplete and a page was missing from the records. The DON confirmed that the lack of accurate recordkeeping and the number of staff with access to the medication cart contributed to the inability to account for the missing Lorazepam.