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
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The facility failed to ensure accurate pharmaceutical services for two residents and related medication storage and recordkeeping. An LPN administered a resident’s insulin glargine pen without priming it first, and a controlled medication log for another resident’s hydrocodone-acetaminophen did not match the blister pack count. In addition, a controlled substance reconciliation log for a medication aide cart had been signed before shift change, and an expired IV tubing supply was found in the LTC medication room.
Medication Error Not Investigated or Documented: The facility failed to investigate, document, and address a reported Zepbound medication error for a resident with moderate cognitive impairment and multiple diagnoses. The event report noted a wrong dose, but the record contained no clear explanation of what occurred, no documented root cause investigation, and no documented actions taken; the DON and RN both stated the process was incomplete, and the consultant pharmacist noted the expected documentation and follow-up for medication errors.
Controlled medications were not properly tracked because the narcotic accountability sheets in one medication cart had multiple entries without the required signatures from two nurses. During the audit, RN #1 and the DON both confirmed that two nurses should have signed the narcotic count sheets.
Controlled substance records were not properly maintained for the Hall A and Hall B medication carts because shift-change narcotic count signatures were missing on multiple occasions. LVNs stated that two nurses were not verifying the count by signing the book, and the DON, ADM, and CCN confirmed that missing signatures meant there was no proof the count was completed and accurate. The facility policy required a physical inventory of controlled meds at each shift change by two licensed nurses or an allowed nurse and med aide.
Incorrect Zyprexa Dose Remained Active on MAR: A resident with psychotic disorder and hallucinations had a Zyprexa dose reduced per MD order, but the prior 10 mg order was not discontinued and both the 5 mg and 10 mg doses remained active on the MAR. The MAR showed both doses were administered daily until clarification was entered, and the LVN stated he entered the new order but thought the old order had been discontinued.
A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Pharmaceutical Services and Controlled Substance Recordkeeping Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs and to ensure drug records were in order for two residents, one medication cart, and one medication room. Resident #8 had diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus, and his MDS documented severe cognitive impairment and insulin use. During a medication pass observation, an LVN administered 15 units of Insulin Glargine pen without priming the pen first. The LVN stated priming was important to ensure the pen was working properly and that failure to prime could affect the dose received. Resident #20 had diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica, and her MDS documented severe cognitive impairment and active sciatica. During observation of the nurse cart, the controlled medication log for Hydrocodone-Acetaminophen 7.5-325 mg did not match the blister pack count: the log showed 6 tablets should have been available, but the pack contained 5 tablets. The LVN stated the tablet should be logged out immediately after administration. The facility also observed that the controlled medication reconciliation log for the 500 hall medication aide cart had been signed in advance of the next shift change, and the medication aide stated it should not be signed early because the cart could be taken away and something could go missing. During observation of the LTC unit medication room, an expired IV tubing supply was found on the shelves with medication equipment and supplies. The LVN stated expired items should not be in the storage room, and the DON and Administrator both stated expired supplies should not be in the medication rooms. The facility policy for insulin pen use required a safety test before each injection, and the controlled medications policy required immediate documentation after administration and a physical inventory at each shift change.
Medication Error Not Investigated or Documented
Penalty
Summary
The facility failed to ensure a reported medication error involving Zepbound for a resident with moderate cognitive impairment and diagnoses including morbid obesity, cerebral palsy, and obstructive sleep apnea was investigated, documented, and addressed in accordance with facility policy. The resident’s event report identified a wrong dose on 4/22/26, but the report did not identify any investigation into the event or any actions taken to prevent further events, and the medical record contained no further information about the incident. During interviews, the DON stated there was a lapse in the process and that an investigation was not completed. The DON reported staff explained the medication did not come from the pharmacy and that the resident did not receive the dose, although the event report stated wrong dose. RN-A also stated there was no documentation explaining what occurred or what actions were taken. The consultant pharmacist stated staff were expected to complete a thorough root cause investigation and analysis, with follow-up and detailed documentation for any medication error, including resident assessment, physician notification when indicated, monitoring for adverse effects, and measures to prevent recurrence. The facility policy stated that when a medication error occurs, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation, or treatment is indicated, and that medication errors are tracked and trended for quality improvement purposes.
Incomplete Narcotic Count Documentation
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion because the facility failed to ensure the narcotic accountability sheets were properly signed by licensed nurses. During a medication cart audit, multiple dates were found on the narcotic accountability sheets without a documented on-coming or off-going licensed nurse signature, including several entries in late April, May, and early June. RN #1 stated that two nurses should have signed the narcotic accountability sheet and had not, and the DON also stated that two nurses should have signed off on the narcotic count sheets.
Missing Controlled Substance Count Signatures on Medication Carts
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for the Hall A and Hall B medication carts. During record review, the narcotic books for both carts were found to have missing signatures documenting shift-to-shift controlled substance counts. On the Hall A medication cart, signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/2026, 1/30/2026, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026. On the Hall B medication cart, signatures were missing on 5/3/2026 and 5/30/2026. During interviews, LVN G and LVN F stated that two nurses were not verifying the narcotic count by signing the book and that, if the count was off, there would be no way to know who to contact or verify that two nurses had counted the medications. The DON stated that when the narcotic book lacks signatures, the count could be incorrect and directly affect the medications the resident receives. The ADM stated missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for residents. The CCN stated that without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. The facility policy required a physical inventory of controlled medications at each shift change by two licensed nurses or an allowed nurse and medication aide, documented on an audit record or accountability record.
Incorrect Zyprexa Dose Remained Active on MAR
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #32 when the facility failed to discontinue an old Zyprexa 10 mg order after the dose was changed to 5 mg in the evening. Resident #32 was admitted with a diagnosis of psychotic disorder with hallucinations and was documented as rarely/never understood with severely impaired cognition. The resident’s care plan addressed psychotropic medication use and gradual dose reduction considerations, and a pharmacy recommendation was made to decrease Zyprexa from 10 mg to 5 mg in the evening, which was signed by the physician on 5/22/2026. The active order summary showed both Zyprexa 5 mg and Zyprexa 10 mg as active, and the MAR showed both doses were administered daily from 5/22/2026 until a clarification order was entered on 6/3/2026. During interview, LVN A stated he received the dose reduction order, notified the hospice provider, entered the new 5 mg order, and thought he had discontinued the 10 mg order, but did not know why it remained active. The DON stated the charge nurse was responsible for entering new orders into the MAR and later obtained clarification from hospice regarding the medication dose.
Failure to Provide Ordered Phosphate Binder
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administration of medications for Resident #59, who was admitted with ESRD, type 2 diabetes mellitus with unspecified complications, depression, anxiety, bipolar disorder, and parkinsonism. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the EMAR showed an order for Sevelamer Carbonate (Renvela) 800 mg, 1 tablet by mouth before meals for disorders of phosphorus metabolism, with a start date of 04/17/2026, but the resident did not receive the medication from 04/18/2026 through 04/30/2026. Further review of the May 2026 EMAR showed the same Renvela order with multiple hold periods, and the resident did not receive any doses during that month. Review of the June 2026 EMAR showed the medication remained on hold and had not been administered from 06/01/2026 through the time of review. The dialysis RD stated the resident was on a fluid restriction and was prescribed Sevelamer Carbonate because of elevated phosphorus, that dialysis and the facility communicated through forms and faxed orders, and that the medication had been filled last on 03/27/2026 and 04/20/2026. Staff interviews revealed the facility believed dialysis normally refilled the medication, but the pharmacy said it could fill it if needed. The DON stated she did not know the resident had gone without the medication and confirmed the facility did not have it readily available even though it should have.
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