Failure to Securely Store Controlled Substances in Medication Room
Penalty
Summary
The deficiency involves the failure to securely store controlled substances in the medication room, specifically Norco prescribed for two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8, on top of a cabinet in the medication room while they were due to be wasted. When V3 returned from break, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4's unzipped personal shoulder bag, with the narcotic sheets still attached and visible. The Director of Nursing (V2) confirmed that she removed the medications from V4's personal bag and stated that narcotic medications in the medication room should be double locked. The Assistant Director of Nursing (V12) stated that narcotic medications stored in the medication room should not have been left on the cabinet and should have been placed back in the locked narcotic drawer in the medication cart. The Administrator (V1) confirmed that the narcotic medications found in V4's personal bag belonged to R7 and R8. R7 had multiple diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg with different dosing frequencies in July and August 2025. R8 had multiple diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in early August 2025. The facility’s Storage of Medications Policy stated that medications and biologicals are to be stored safely, securely, and properly, but the handling and storage of these Norco bingo cards did not comply with those requirements.
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