Failure to Properly Destroy and Discontinue Controlled Substances
Penalty
Summary
The facility failed to ensure proper destruction and disposition of controlled substances for two residents, contrary to its policy requiring unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and with a witness to the destruction. For one resident, documentation showed an order for Pregabalin (Lyrica) 50 mg capsules twice daily that was later discontinued and changed to Pregabalin (Lyrica) 75 mg twice daily. The narcotic sheet for the 50 mg dose had an "X" across the sheet with a notation "Destroyed RN" and only one nurse’s signature. During interview, the DON stated that controlled substances should be discarded right away once it is known the resident will not be using them or when the provider discontinues the order, and acknowledged that the 50 mg Pregabalin should have been destroyed immediately and with two licensed staff, but was not. For another resident, Lorazepam oral concentrate 0.25 ml every four hours as needed for terminal anxiety was prescribed, but the facility’s controlled substance log initiated for this resident was labeled for Lorazepam 0.5 mg tablets. The log showed documentation that the resident continued to receive Lorazepam after the medication had been discontinued. In interviews, the DON and ADON acknowledged awareness of medication errors related to this situation. A registered nurse described the usual process for controlled substance destruction as using a drug buster in the medication storage room with two nurses signing off and verifying destruction, which contrasted with the documented practice in these cases.
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