F0755

D

Unsecured Controlled Substances and Missing Oxycodone Blister Pack

Bristol, Connecticut Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to secure and account for controlled substances in accordance with its own Controlled Substance Administration & Accountability policy. A resident admitted with a right femur fracture had physician orders for Oxycodone 5 mg every four hours as needed for pain and Lyrica (Pregabalin) 200 mg twice daily for nerve pain, and the resident’s care plan included administration of pain medication as ordered. Pharmacy documentation showed that two 30-count blister packs of Oxycodone 5 mg and two 30-count blister packs of Lyrica 200 mg were delivered for this resident and signed for by an RN.

The facility’s documentation identified that Controlled Substance Disposition Records (CSDRs) were created for two 30-count Lyrica blister packs and only one 30-count Oxycodone blister pack, despite the pharmacy packing slips and proof of delivery indicating that two Oxycodone blister packs had been delivered. A reportable event completed by the DNS documented that video review showed the RN receiving four blister packs (two Lyrica and two Oxycodone) from the pharmacy driver and delivering them to an LPN, who was observed on video with all four blister packs at the nursing station and then at the medication cart. However, only three blister packs (two Lyrica and one Oxycodone) were documented as received by the LPN.

In interview, the LPN stated she was working the 11:00 PM to 7:00 AM shift when the RN brought the controlled substances to her unit. She reported that the RN placed the blister packs on top of her medication cart in the hallway, that she did not verify the number of blister packs at the time of transfer because she was in a rush, and that she left the controlled substances unsecured on top of the cart while she went to administer another resident’s medication. She later returned and signed in only three blister packs into the controlled substance records. The DNS described the facility’s process, which requires the supervisor and unit nurse to verify each blister pack at hand-off, immediately record the medications on the appropriate drug disposition record, and store patient-specific controlled substances under double lock, and confirmed that controlled substances should not be left unattended and should always be secured. One 30-count blister pack of Oxycodone remained unaccounted for.