F0755

D

Failure to Maintain Accurate Control and Accountability of Ambien for a Resident

Granger, Iowa Survey Completed on 02-26-2026

Penalty

No penalty information released

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.