Failure to Timely Destroy and Document Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain an ongoing monitoring process for the documentation, destruction, and accountability of expired or unusable medications, particularly controlled substances. Surveyors observed that a locked file cabinet in the DON/ADON's office contained numerous discontinued and expired medications for approximately 34 residents, including controlled substances such as morphine, lorazepam, temazepam, fentanyl, tramadol, pregabalin, and haloperidol. Many of these medications lacked the required individual narcotic accountability sheets, and some had been retained for several months after residents had expired or been discharged. The facility's own policy required prompt removal and destruction of such medications, with documentation by two licensed nurses, but this was not followed. Interviews with staff, including the ADON, LPNs, the physician, the pharmacist, the DON, and the administrator, revealed a lack of awareness and responsibility regarding the destruction of discontinued medications. The ADON, new to the position, was unaware of the quantity of medications stored and had not participated in any destruction process. LPNs reported that discontinued medications were given to the DON for destruction but had not witnessed any destruction events. The DON admitted to not having destroyed any medications with the ADON and was unable to locate the Drug Destruction Log, resulting in medications being stored indefinitely in the file cabinet. The DON and administrator both acknowledged that the number of discontinued medications on hand was unacceptable and not in line with facility policy. The facility did not provide a logbook documenting the destruction of controlled substances, as required by policy. Observations and interviews confirmed that medications were not destroyed within the expected 30-day timeframe, and there was no evidence of the required dual-nurse destruction process or proper documentation. The physician and pharmacist both stated that medications should be destroyed promptly to prevent diversion, and the facility's failure to do so was attributed to high staff turnover and lack of clear responsibility.