F0755

D

Failure to Document Witnessed Disposal of Controlled Medication Waste

Meyersdale, Pennsylvania Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to maintain accountability for controlled medications for one resident receiving Ativan. Facility policy dated April 7, 2025, required that waste or disposal of controlled medications be completed in the presence of the nurse and a witness, with both signing the disposition sheet. For this resident, physician orders dated January 14, 2026, directed administration of 0.25 mg of Ativan twice daily by cutting a 0.5 mg tablet in half, with the remaining 0.25 mg half tablet to be disposed of as waste. The January 2026 MAR reflected the ordered 0.25 mg twice-daily dosing, and the controlled drug count record showed that 0.5 mg tablets were being split to obtain the prescribed dose.

However, review of the controlled drug count record revealed no documented evidence that two staff members witnessed and signed for the disposal of the unused 0.25 mg half tablets on multiple specific dates and times in January 2026. These missing dual signatures occurred on January 17 at 7:55 p.m., January 21 at 8:12 a.m., January 23 at 8:16 p.m., January 28 at 7:26 p.m., and January 31 at 9:07 p.m. The resident involved had a quarterly MDS dated January 15, 2026, indicating cognitive impairment, dependence for care needs, signs of delirium, and diagnoses including dementia, anxiety, depression, and psychotic disorder, and was receiving controlled antianxiety medications. In an interview on February 18, 2026, at 3:11 p.m., the Director of Nursing confirmed there was no documentation that two staff members witnessed and signed for the disposal of the half tablets on the identified dates and times.