Failure to Properly Document and Destroy Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for, document, and destroy controlled medications in accordance with its own policies for multiple residents. The facility’s Controlled Substance Destruction Policy requires that controlled substances be destroyed by a licensed nurse and a licensed professional, with the destruction, quantity destroyed, and date documented on the controlled medication count sheet and signed by both individuals. The Controlled Substance Policy also requires nurses to sign out controlled medications on the Controlled Substance Proof of Use Form immediately and document administration on the MAR immediately after giving the dose. For one resident (R9), the Controlled Substance Record for Diazepam 2 mg showed single doses dispensed on four late-night occasions, all signed by an LPN, but these administrations were not recorded on the resident’s January and February MARs because there was no active order entered after 1/22/26. The resident’s census showed discharge on 2/14/26, and a subsequent check of the medication cart revealed remaining Diazepam tablets still present after discharge. The DON later confirmed that an active Diazepam order existed from the pharmacy but had not been entered into the electronic medical record and MAR, and the LPN acknowledged administering the medication “out of habit” without verifying it on the MAR. For another resident (R7), the Controlled Substance Record documented destruction of remaining Lorazepam and Norco tablets by an LPN on 2/9/26. The Narcotics Destruction Form for that date also listed destruction of multiple controlled medications for R7 and a third resident (R15), including Norco tablets, Morphine Sulfate solution, Lorazepam concentrate, and Fentanyl patches. However, these destruction forms contained only the LPN’s signature and lacked the required second signature of a witnessing licensed professional, contrary to the facility’s policy that controlled medications are destroyed with a floor nurse and either the DON or ADON, with two signatures documented. The DON and ADON both stated that they participated in the destruction but acknowledged that the ADON forgot to sign the destruction forms, leaving the documentation incomplete and not in compliance with the facility’s controlled substance procedures.
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