Failure to Maintain Accurate Control and Accountability of Ambien for a Resident
Summary
The deficiency involves the facility’s failure to maintain accurate control and accountability of a Schedule IV controlled hypnotic medication (Ambien) for one resident. The resident had diagnoses including diabetes, depression, and primary insomnia, with an MDS indicating no cognitive impairment and use of a hypnotic. Physician orders on the MAR for Ambien 5 mg at bedtime were documented for December and January, with administration entries showing doses given on multiple days and held on days when the resident was hospitalized. The resident’s Individual Patient’s Narcotic Record for Ambien showed an order dispensed on 12/12/25 with a quantity documented as 30, later altered to appear as 31 by writing a “1” over the “0,” and the first dose recorded as given on 12/20/25 with 30 pills remaining. The controlled drug record entries documented one tablet administered daily from 12/20/25 through 12/29/25, and then from 1/2/26 through 1/6/26, with the running balance decreasing by one each time. On 1/7/26, the record showed one tablet dropped and wasted with two staff initials, leaving 15 remaining, and another tablet given the same day, leaving 14. On 1/8/26, two separate recount entries were made, both signed by two staff, documenting 12 tablets remaining. Staff interviews revealed that during the 1/8/26 morning shift change narcotic count, an RN and an LPN identified that the Ambien count was off by one or two tablets, with the RN stating the count was incorrect and refusing initially to sign off on the narcotic count. The RN reported that the LPN, who had the cart keys on night shift, suggested pills may have popped out of the card due to a full drawer, but the RN did not find any loose pills in the drawer. Further interviews clarified that the facility’s Controlled Drugs-Count Record for that date nonetheless contained signatures from the RN and the LPN, with a comment of the total number of controlled cards and bottles, and an instruction on the form that signing acknowledges agreement with the quantities on hand. The DON stated he was notified of a discrepancy on the cart and that no one was willing to sign for the cart being accurate, and he verbally interviewed staff but did not document those interviews or obtain written statements. The ADON reported that upon recount she determined that one Ambien tablet was unaccounted for, based on the count sheet showing a jump from 14 remaining to 12 remaining, and she confirmed there was no photocopy of the bubble pack to verify the original quantity or any pills that may have popped out. The pharmacist and pharmacy shipping manifest confirmed that only 30 Ambien tablets were dispensed and delivered, while the narcotic record had been altered to appear as 31 received. The nurse who signed as receiving the medication stated she documented 30, denied changing the number, and explained she would have properly lined out and initialed any correction rather than writing over the number. The CMA who first administered the medication also denied altering the received quantity and stated she believed there were 30 tablets remaining after the first dose, consistent with her documentation. The facility’s Controlled Substances policy required accurate counting upon delivery, proper documentation of quantity received, end-of-shift counts by oncoming and outgoing nurses, documentation and reporting of discrepancies to the DON, and investigation of any narcotic reconciliation discrepancies, which was not fully supported by the documentation and events surrounding the missing Ambien tablet and altered quantity on the narcotic record. An additional staff interview indicated that on the evening before the count discrepancy, the night-shift nurse reported dropping an Ambien tablet, which another nurse observed and then observed being disposed of in the dissolvable medication waste container. The next morning, during the narcotic count with the RN and the night-shift nurse, the count was short by one pill, and the night-shift nurse reported that one pill was missing. The Director of Clinical Services confirmed that following the documented administration pattern, the record would show a discrepancy of two pills short on 1/8/26 and noted that the received quantity on the narcotic record appeared to have been changed from 30 to 31 by writing a “1” over the “0.” These combined documentation irregularities, the unaccounted-for Ambien tablet(s), and the lack of clear, contemporaneous investigative documentation demonstrate that the facility did not ensure accurate control and accountability of this controlled medication for the resident, in contrast to its written controlled substances policy. The facility’s own policy on controlled substances, revised December 2012, required that controlled substances be counted upon delivery by both the receiving nurse and the delivery person, with both signing the designated record, and that an individual resident controlled substance record include the quantity received and number on hand. It also required nursing staff to count controlled medications at the end of each shift, with both oncoming and outgoing nurses making the count together and documenting and reporting any discrepancies to the DON, and required the DON to investigate any discrepancies and provide the administrator with a written report of findings. In this case, the altered quantity on the narcotic record, the missing Ambien tablet(s), the inconsistent count documentation, and the absence of a written investigative report or staff statements show that these policy requirements were not fully met for this resident’s controlled medication. Overall, the events leading to the deficiency include the pharmacy’s documented dispensing of 30 Ambien tablets, the facility’s narcotic record being altered to appear as 31 tablets received, the administration and waste documentation that did not reconcile with the remaining count, the discovery of a missing tablet during shift-change counts, and the lack of complete, accurate documentation and investigation consistent with facility policy. These factors resulted in the facility’s failure to ensure accurate control and accountability of the resident’s controlled hypnotic medication.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to reconcile liquid controlled narcotics during a shift change count. An RN counted only the pill narcotics in the locked med cart box and left 7 bottles of liquid controlled meds uncounted, stating liquid morphine was hard to count. Other staff, including the DON and consulting pharmacist, confirmed that all controlled meds, including liquids, should be reconciled shift to shift per policy.
Incorrect Medication Route Transcribed on MAR: A resident with cerebral infarction, dysphagia, and gastrostomy status had an order for acetaminophen 650 mg by mouth PRN pain, but the MAR reflected the route incorrectly. During observation, the resident received medications through the G-tube, and the LVN stated she had transcribed the wrong route into PCC even though the resident was NPO. The DON stated new orders are transcribed by the charge nurse and reviewed by nurse managers.
A resident with cognitive intactness, wheelchair use, and multiple diagnoses had groin redness and a provider order for nystatin powder, but staff also kept an unlabeled bottle of 2% miconazole nitrate at the bedside without a provider order. Staff and the resident described self-administration, yet the TMA documented the ordered nystatin as given even though she later said it remained in the cart and was not administered, and staff were unclear about which antifungal powder was being used.
Failure to Monitor Controlled Narcotics in E-kit: The facility failed to monitor controlled narcotic medications in an E-kit stored in a med cart. RN-A stated the plastic numbered tag on the E-kit was not checked daily or documented, and both RN-A and TMA-A said there would be no way to know if the kit had been opened and narcotics removed until the kit was accessed for needed meds. The E-kit contained controlled meds including tramadol, hydrocodone/APAP, lorazepam, and morphine solution, and the DON stated staff should have been monitoring the tag number.
A resident with diabetes had insulin glargine documented as held on multiple occasions even though the DON stated it was administered as ordered, and a second resident's PRN Norco was signed out on the controlled drug record but not documented on the MAR. Facility policy required medications to be given per MD order and controlled meds to be documented on both the accountability record and MAR.
An LVN prepared medications for two residents on one tray and intended to administer them one after the other, rather than for one resident at a time. One resident had osteoarthritis and the other had liver cancer; both were cognitively intact and required substantial to maximal assistance with ADLs. During observation, the LVN carried two medication cups and water into the roommates’ room, gave one resident’s medication while the other was busy, and stated she saw no issue with preparing and administering both residents’ medications together. The DON stated medications should be prepared and given to one resident at a time, and facility policy said medications are administered when prepared and are not pre-poured.
Failure to Reconcile Liquid Controlled Narcotics During Shift Change
Penalty
Summary
The facility failed to reconcile liquid controlled narcotic medications in 1 of 2 medication carts during the shift change narcotic count. During observation and interview, RN-B counted the narcotic pills in the locked box of the medication cart while LPN-A confirmed the pill count, then RN-B locked the box and cart without picking up or confirming the amounts of 7 bottles of liquid narcotic medications also stored in the locked box. RN-B stated the liquid morphine was not counted because it is hard to tell as a liquid, although the facility documented administration of the liquid narcotics in the narcotic book. The unreconciled medications included liquid morphine, codeine solution, and lorazepam solution for residents R7, R8, R23, R26, R36, and R53. Interviews with other nursing staff, the DON, the regional clinical service director, and the consulting pharmacist confirmed that all controlled medications, including liquid narcotics, should be reconciled shift to shift. Staff stated that everything in the locked box should be counted to confirm the correct amount remained, and the DON identified that nurses should count all narcotics between two staff members. Review of the facility's controlled medication policy stated that all controlled medications are to be verified when delivered and that each time the keys secure the controlled medication locked box, the oncoming and off-going nurse or medication aide should reconcile all controlled medications to ensure the count matches the remaining amount listed.
Incorrect Medication Route Transcribed on MAR
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #35 by inaccurately transcribing a physician-ordered medication onto the Medication Administration Record. Resident #35 was an adult male admitted with diagnoses including cerebral infarction, dysphagia of the oropharyngeal phase, and gastrostomy status, and his care plan identified that he required tube feeding related to stroke. His orders included NPO status and an order for acetaminophen 325 mg tablets, 2 tablets by mouth every 6 hours as needed for pain. During observation of medication administration, the resident did not receive acetaminophen, and scheduled medications were administered through the gastrostomy tube. Record review showed the MAR documented acetaminophen 650 mg as given, but the route was reflected incorrectly. The LVN who received the original order stated she had accidentally marked the wrong route when transcribing it into PCC and that she administered the dose through the gastrostomy tube because the resident was NPO. The DON stated the charge nurse is responsible for transcribing new physician orders into PCC right away and that the incorrect route was missed during review.
Medication Given and Documented Without Proper Order
Penalty
Summary
The facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for one resident who was cognitively intact, used a wheelchair, and had diagnoses including bilateral subdural hematomas related to a fall, congestive heart failure, and chronic kidney disease. The resident was occasionally incontinent of urine and required moderate assistance with lower body dressing and toileting. A nursing progress note documented redness in the groin related to moisture, and the provider later ordered nystatin external powder to the groin three times daily for 14 days for candidiasis related to rash and other nonspecific skin eruption. Despite that order, the resident’s record did not contain a provider order for 2% miconazole nitrate powder. Surveyors observed a container of 2% miconazole nitrate antifungal powder on the resident’s bedside table on two occasions, and the container did not have a pharmacy prescription label. The resident stated staff had given him the powder and that he could use it as needed, while a nursing assistant stated staff were supposed to help apply it but the resident preferred to do it himself and refused staff assistance or removal of the medication from the room. During interviews, nursing staff stated orders should be in the system for all medications, including topicals and self-administered medications. A review of the MAR showed the nystatin powder was documented as administered, but the TMA later stated it had remained in the cart that morning and was not given, and that she charted it as administered after the resident said he would do it later and later told her he had done it himself. The TMA also produced a separate bottle of 2% miconazole nitrate from the medication cart and confused it with the nystatin order, while the DON stated no medications should be administered without a provider order and that medication administration should be documented accurately.
Failure to Monitor Controlled Narcotics in E-kit
Penalty
Summary
The facility failed to monitor controlled narcotic medications in 1 of 1 emergency kits (E-kits) to prevent potential diversion. During observation and interview, the E-kit was found stored in the medication cart, with a small plastic E-kit box inside a locked box on the cart containing controlled narcotic medications. RN-A stated the nurses did not monitor the plastic numbered tag on the E-kits daily, and the tag was not documented anywhere to confirm the correct tag remained in place. Both TMA-A and RN-A stated there would be no way to know if someone had opened the E-kit and removed narcotics until the nurse accessed it for needed medication, and RN-A acknowledged the kit and the smaller box were not opened regularly, so medication could be missing for quite some time before anyone would notice. Review of the E-kit medication list showed controlled narcotics including Tramadol 50 mg, Hydrocodone/APAP 5/325 mg, Lorazepam 0.5 mg, and Morphine solution 20 mg/ml. The DON stated staff should have been monitoring the number on the plastic tag of the E-kit and the E-kit located inside the locked box on the medication cart, and a policy on monitoring controlled narcotic medications was requested but not provided.
Medication Administration and Controlled Drug Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for two residents. For one resident with diabetes mellitus, the physician ordered insulin glargine 27 units subcutaneously at bedtime and regular human insulin before meals and at bedtime per sliding scale. The order summary did not include any hold parameters for insulin glargine, yet the MAR showed the insulin glargine dose was held on multiple dates in July 2026. On those same dates, the regular human insulin was held appropriately based on the documented blood sugar values. During interview and record review, the DON acknowledged the insulin glargine doses were shown as held on the MAR but stated the medication had been administered as ordered. For another resident, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for severe pain, not to exceed 3 g in 24 hours. The facility's controlled medication record showed one tablet was dispensed and signed out, but the MAR did not show documentation that the dose was administered. The resident's H&P indicated the resident had the capacity to understand and make decisions. An LVN and later the DON reviewed the record and verified that the medication had been pulled and that there was no documented evidence on the MAR. Facility policy required medications to be administered according to physician orders and required controlled medications to be documented on both the accountability record and the MAR at the time of administration. The survey findings showed that insulin glargine was documented as held on the MAR despite the DON stating it had been given, and that a controlled pain medication was signed out but not documented as administered on the MAR.
Medication Prepared for Two Residents on One Tray
Penalty
Summary
The facility failed to ensure that an LVN did not prepare medication for two residents on one tray with the intent of administering the medications sequentially. Resident 4 had osteoarthritis, intact cognition, and required substantial to maximal assistance with ADLs; his physician’s order included hydrocodone-acetaminophen 10-325 mg, one tablet every 4 hours as needed for severe pain. Resident 5 had liver cancer, intact cognition, and required substantial to maximal assistance with ADLs; her physician’s order included oxycodone HCl 5 mg every eight hours for pain. During a medication administration observation, the LVN was seen carrying two medication cups, each with one pill, and two cups of water on one tray to the roommates’ room. When Resident 5 was being transferred from a wheelchair to the bed, the LVN stated she would administer Resident 4’s medication first and return later for Resident 5’s medication. The LVN stated she knew both residents well and saw no issue with preparing and administering their medications together. The DON stated medications should be prepared and given to one resident at a time because preparing medication for multiple residents simultaneously could result in giving the wrong medication to the wrong resident. The facility policy stated medications are administered at the time they are prepared and are not pre-poured, and medications are administered without necessary interruptions.
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