F0755

E

Unsecured and Unaccounted Controlled Medications and Narcotic Records

San Marcos, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that controlled medications and associated Individual Patient’s Narcotic Records (IPNRs) were properly secured and accounted for in the medication carts. Controlled substances and original narcotic sheets were removed from the carts without the knowledge of licensed nurses and were later discovered at another skilled nursing facility during a drug diversion investigation involving an agency nurse. The facility’s Administrator stated that original narcotic sheets and medication bubble packets traced back to this facility were found elsewhere, indicating that controlled medications and records had been taken from the facility without staff awareness.

Record review for ten residents showed multiple discrepancies and documentation gaps related to controlled medications. For one resident with liver cancer and a PRN order for Tramadol, the pharmacy packing slip showed 30 tablets received, while the IPNR indicated 26 tablets remaining in the bubble pack. Another resident with chronic back pain and orders for Hydrocodone-Acetaminophen and Oxycontin had multiple controlled prescriptions where the number of tablets dispensed per pharmacy packing slips did not clearly reconcile with the remaining counts documented on the IPNRs. Additional residents with chronic pain, venous ulcers, ischemic colitis, chronic pain syndrome, end-stage renal disease, cervical disc disorder, bilateral knee osteoarthritis, and a leg fracture had controlled medications such as Oxycodone and Oxycodone-Acetaminophen dispensed, but several pharmacy packing slips were undated, lacked licensed nurse signatures acknowledging receipt, or were missing altogether. In some cases, IPNRs showed remaining tablets, in others they showed zero tablets left, and there were missed nurse signatures on the narcotic records.

Interviews with the Director of Staff Development and licensed nurses described the facility’s intended process for receiving and counting controlled medications, including signing pharmacy packing lists, maintaining a narcotic binder, and performing shift-to-shift counts where incoming and outgoing nurses verified bubble pack quantities against the narcotic count sheets. However, one nurse stated that when new refills were received, the receiving nurse documented only the number of cards received, not the quantity of pills, and several packing slips in the records lacked any nurse signature to confirm receipt of the medications. Despite these described procedures, the Administrator and DON reported they were unaware of any discrepancies in controlled drug counts until notified of the external drug diversion investigation, indicating that controlled medications and narcotic records had been removed from the carts and left unaccounted for without detection by the facility’s counting and reconciliation processes.

The report notes that there were no missed doses for the affected residents, but controlled substances and IPNRs for all ten residents were removed from the medication carts without the knowledge of the licensed nurses and were not accounted for within the facility’s own systems. The combination of missing or unsigned packing slips, incomplete documentation of quantities received, missed signatures on narcotic records, and the discovery of original narcotic sheets and bubble packs at another facility demonstrate that the facility did not maintain secure control and accurate accountability of controlled medications as required.