Improper Storage and Documentation of Controlled Substance Intended for Destruction
Penalty
Summary
The deficiency involves the facility’s failure to properly store a DEA-controlled substance (diazepam/valium) intended for destruction in accordance with its policy and professional standards. Surveyor observation of the medication carts and the medication/drug storage room showed that narcotic medications in the locked narcotic cabinet were reconciled and stored under a double-lock system in the DON’s office. However, a biological waste box in the same locked room contained multiple medications and one narcotic blister pack of diazepam 5 mg, prescribed as 1 tablet PRN 30 minutes prior to imaging for Resident #3, without an accompanying resident medication sheet. Record review showed no physician order or administration record for diazepam for this resident in December 2025. Staff interviews confirmed that this narcotic blister pack was not stored in the required double-locked container and lacked the required resident sheet. Resident #3 was an adult male with diagnoses including surgical aftercare on the digestive system, vertigo, and intestinal obstruction, with a BIMS score of 13 indicating no cognitive impairment and requiring only supervision for transfers and mobility. The resident reported bringing a urologist-prescribed blister pack medication into the facility around New Year and giving it to an unknown nurse, and did not recall the purpose of the medication or whether he received any doses. The ADON stated that the resident returned from pass with diazepam and gave it to an unknown nurse, and that she later found the medication in a medication cart and threw it into the biological waste box in the locked DON storage room instead of placing it in the double-locked narcotic container or completing a resident narcotic sheet. The LVN, pharmacist, administrator, and DON each confirmed that controlled substances scheduled for destruction were required to be stored in a two-lock system with a corresponding resident sheet, and that the facility’s practice in this instance did not follow those procedures. The facility’s Controlled Substances policy stated that controlled substances remaining after discontinuation or discharge are to be securely locked in an area with restricted access until destroyed.
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