F0755

E

Failure to Maintain Accountability and Documentation for Controlled Medications

Lumberton, North Carolina Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and handling of controlled medications for nine residents. For multiple residents with active or time-limited PRN orders for controlled substances such as lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol, pharmacy packing slips and proof-of-delivery records showed that controlled medications were dispensed and delivered to the facility. However, for these deliveries, the facility frequently lacked required documentation, including missing declining count sheets (narcotic inventory logs) and incomplete or absent nurse signatures on delivery receipts. In one case, a resident had an order for lorazepam 0.5 mg every 24 hours as needed for anxiety for 14 days, with 14 tablets delivered, but there was no declining count sheet, no narcotic book entry, and no MAR documentation that any doses were administered after delivery.

For several other residents, similar documentation gaps were found. Residents with active orders for hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol had controlled medications delivered in quantities ranging from 30 to 90 tablets, but there were no corresponding declining count sheets located for any of these medications. In many instances, the delivery receipts were signed by only one nurse, often the same nurse, or had no nurse signature at all, despite the presence of two signature lines intended for verification by two nurses. The DON later confirmed that declining count sheets were missing for nine residents whose controlled medications had been delivered during the review period, and that the missing lorazepam tablets for one resident had not been returned to the pharmacy and were not documented as administered.

Interviews with facility and pharmacy staff further described how these documentation failures and lack of oversight contributed to the deficiency. The DON explained that prior to the discovery of missing medications, the process for receiving controlled drugs involved whichever nurse was available distributing medications from the delivery tote to the medication carts and signing the delivery sheet, without consistent second-nurse verification. The DON also stated she did not verify that medications documented on delivery sheets were actually present on the carts and did not identify the absence of declining count sheets until missing medications were reported. The Unit Manager reported that she did not audit controlled medications and believed the DON was responsible. The Consultant Pharmacist stated she did not conduct controlled medication cart audits and believed the pharmacy’s Nurse Consultant did random checks, while the Pharmacy Nurse Consultant stated he only verified that narcotic boxes were locked and did not review controlled medications or declining count sheets. The Pharmacy Director confirmed that the pharmacy did not track discontinued controlled medication orders and relied on the facility to remove and return discontinued medications, which did not occur for at least one resident’s discontinued lorazepam order.