Unauthorized CNA Access to Medications and Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to restrict access to medications, including Schedule II controlled substances, to authorized licensed personnel only. Surveillance footage from the evening of 1/15/26 showed a CNA (V5) removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking those cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the controlled drug count binder, and opening the medication room door, all without a nurse present. The Administrator (V1) confirmed these observations while reviewing the surveillance footage. Multiple cognitively intact residents reported that V5 personally brought them their medications that evening and that no nurse was present with her. One resident (R1), admitted with anemia, atrial flutter, and hypertension and with a BIMS score of 15, stated that the “dark-haired girl” who had previously been a CNA and whom he believed was now a nurse brought his medications on the evening in question, and he did not see another nurse with her. Another resident (R3), with COPD, type 2 diabetes, and fibromyalgia and a BIMS score of 15, stated she believed V5 brought her medications and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), also cognitively intact with diagnoses including type 2 diabetes, hyperlipidemia, and spinal stenosis, reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Medication records and controlled drug documentation further supported that V5 had access to and handled controlled substances. R3’s controlled drug record for hydrocodone/acetaminophen showed that two tablets were removed from the count on 1/15/26 with both V5 and an LPN (V7) signing the record. R2’s controlled drug record for pregabalin documented that one capsule was removed from the count with both V5 and V7’s signatures. V5 acknowledged holding the keys to the medication cart and medication room and stated that she and V7 both signed out Schedule II medications, claiming V7 had been present while she administered medications. However, V7 later stated she had not been present when V5 administered medications and that she signed the Schedule II count binder only at the end of the shift when they counted the medications together. The DON (V2) stated that only licensed nurses should have access to medication and controlled substance keys and confirmed that V5 was not a licensed nurse, which conflicted with the facility’s controlled substances policy and job description for charge nurses.
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