F0755

D

Failure to Accurately Manage and Document Controlled Substance Use for a Resident in Pain

Maumee, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accurate and compliant system for dispensing, administering, reconciling, and destroying controlled substances, specifically Oxycodone, for a resident with significant pain needs. The resident was admitted with malignant carcinoid tumor of the bronchus and lung, COPD, malignant neoplasm of the liver, and low back pain, and had intact cognition, independence in ADLs, and frequent pain. Physician orders initially included Oxycodone 30 mg every four hours as needed, later changed to Oxycodone 20 mg scheduled three times daily with additional 20 mg doses every four hours as needed. The scheduled and PRN Oxycodone 20 mg orders were placed on the same medication card, contrary to facility policy requiring one prescription per control record page.

Review of the MARs and controlled substance records showed multiple discrepancies and missing documentation. The MARs indicated that the resident received 26 Oxycodone tablets over several days and an additional 28 tablets over a later period, but there were no corresponding controlled substance monitoring/control records for those administrations. On one date, two tablets of discontinued Oxycodone 30 mg were removed from the medication card at 3:00 A.M., with no documentation on the MAR or in nurse’s notes that the medication was administered, disposed of, or wasted. On another date, the MAR showed administration of two Oxycodone 20 mg tablets, but the control record did not show that the medication had been removed from the card, and there was no nursing documentation explaining why the medication was charted as given when it had not been pulled according to the control record.

Further record review revealed inconsistencies in the documented counts and destruction of Oxycodone 30 mg tablets. A disposal record showed nine tablets documented as destroyed, while the corresponding control record indicated only four tablets remained, and the entry for destruction of nine tablets was crossed out and changed to four. The DON verified that nine tablets had been incorrectly documented as destroyed. Facility leadership and nursing staff acknowledged they could not locate all of the resident’s Oxycodone control records and that nurses were not consistently documenting and initialing shift-change controlled substance inventory count sheets when medication cards and control records were removed from the controlled substance binder. The resident reported that pain medication was not administered when requested and stated that management had been notified. Interviews with the ADON and other staff confirmed that required documentation practices, including progress notes when medications were not given and proper witnessing and recording of destruction, were not followed, and that the ADON had not reviewed the missing control records as required by policy.