Failure to Remove Discontinued Controlled Medications and Maintain Accurate Drug Records
Penalty
Summary
The facility failed to properly manage controlled substances by not removing discontinued medications from the medication cart and by not maintaining accurate Controlled Drug Administration Records. Specifically, after physician orders for morphine sulfate and oxycodone/APAP were discontinued for two residents, the medications remained in the medication cart instead of being removed and surrendered to the Director of Nursing for secure storage. This was confirmed during observations and interviews with nursing staff, who acknowledged that discontinued controlled medications should be immediately removed to prevent confusion and potential medication errors. Additionally, the facility did not create a Controlled Drug Administration Record for one of two supplies of oxycodone prescribed to another resident. The pharmacy provided two supplies of oxycodone with different administration instructions—one scheduled and one PRN (as needed)—but only created records for the PRN supply, resulting in the scheduled supply not being accurately tracked. Facility staff failed to identify this discrepancy upon receipt of the medications, leading to incorrect documentation of medication administration. The residents involved had significant medical histories, including prostate cancer with collapsed vertebrae, heart failure with pulmonary edema, and hemiplegia following a stroke. The deficiencies were identified through observation, record review, and staff interviews, which confirmed that the facility's practices did not align with its own policies for the immediate removal of discontinued medications and the preparation of controlled medication accountability records.