Failure to Secure and Account for Controlled-Substance Medication
Penalty
Summary
The deficiency involves the facility’s failure to properly store and account for a resident’s controlled-substance medication in accordance with its own policies and procedures. The facility’s Controlled Substance Administration and Accountability Policy requires controlled substances to be stored in locked compartments with access limited to approved personnel, and for areas without automated dispensing systems to use a two-lock storage unit and a paper system for 24-hour recording. The policy and the Controlled Substance Inventory Count Sheets further require that the oncoming nurse verify all controlled substances with the offgoing nurse at each shift change, including counting total cards/containers and reconciling actual drug counts against individual resident count sheets, with any discrepancies reported immediately to the DON or nursing supervisor. Review of the inventory sheets from 12/6/25 through 12/9/25 showed that two nurses did not count or verify the number of controlled substances or controlled-substance cards within the medication cart for six oncoming/offboarding shifts during that period. Pharmacy documentation showed that 30 tablets of Hydrocodone-APAP 10/325 mg for one resident (R8) were delivered to the facility and received by an agency RN, who was seen on video placing the medication card in the medication cart. The DON later learned from an LPN that a refill request for this resident’s Norco was denied by the pharmacy because it had already been refilled and sent, prompting review of video footage and records. By the time the DON discovered that the resident’s Norco card of 30 tablets was missing from the medication cart, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses had not been performing the required beginning- and end-of-shift controlled-substance counts, contributing to the unaccounted-for loss of the resident’s controlled medication.
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