F0755

D

Failure to Properly Reconcile and Document Controlled Medications

Washington, District Of Columbia Survey Completed on 03-03-2026

Penalty

Fine: $85,666

Summary

Facility staff failed to ensure controlled substances were properly reconciled by not signing controlled medication forms at the time medications were administered for three residents. For one resident with neuralgia, neuritis, hypertension, encephalopathy, severe cognitive impairment, and an order for PRN Tramadol 50 mg every six hours for right arm pain, a controlled substances reconciliation on Unit 2 East showed a discrepancy: the narcotic control sheet documented 2 tablets remaining, while the blister pack contained only 1 tablet. The LPN conducting the reconciliation stated that the medication had just been given and acknowledged forgetting to sign the controlled substance form when the dose was removed and administered.

A second resident with pain, neuralgia, neuritis, muscle spasms, intact cognition, and an order for Pregabalin 150 mg twice daily for neuropathy pain also had a discrepancy during the same reconciliation on Unit 2 East. The controlled substance form showed 18 capsules remaining, but the blister pack contained 17, and the LPN reported forgetting to sign when the medication was given. A third resident with conversion disorder with seizures or convulsions, Crohn’s disease, dementia, severe cognitive impairment, and an order for Lacosamide 200 mg twice daily for seizures had a similar issue on Unit 3 West. During reconciliation, the controlled substance form indicated 18 tablets remaining, while the blister pack had 17 tablets; the RN stated that they were supposed to sign the narcotic sheet when pulling the medication to give to the resident, implying this had not been done. These findings showed that controlled substances were not consistently reconciled as required when administered.