F0755

E

Failure to Properly Receive, Count, and Reconcile Controlled Substances

Fremont, Ohio Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s handling and inventory of controlled substances and narcotic medications for all eight residents who were receiving these drugs. During an early-morning observation, pharmacy delivery staff handed a package of medications, including controlled substances, to an LPN, who did not count the medications or review the contents with the delivery person before the delivery staff left the building. The LPN then placed medication cards, including those containing controlled/narcotic medications, into two medication carts without any second staff member present to monitor or verify the placement. A subsequent reconciliation count of narcotic medications in the front medication cart showed a discrepancy between the documented inventory and the actual number of tablets for an oxycodone 5-325 mg prescription for one resident.

The control substance inventory sheet for this resident’s oxycodone listed a total of 23 tablets, while the medication card contained only 22 tablets. In an interview at the time of the observation, the LPN confirmed that the reconciliation count was not accurate and stated that she had previously administered a dose of the medication to the resident but had not recorded the removal on the controlled substance inventory sheet at the time of administration. Review of the facility’s controlled substances policy showed that controlled substances are required to be counted upon delivery by both the receiving nurse and the delivery person, with both signing the controlled substance record, and that controlled medications are to be counted at each shift change by the oncoming and outgoing nurses together. The Regional RN later confirmed that medication delivery requires a joint count by the receiving nurse and delivery personnel, including when narcotics are delivered.