Failure to Timely Dispose of Discontinued Controlled Substance
Penalty
Summary
Facility staff failed to follow their policy for timely disposal of a controlled substance for one resident. The facility’s policy on discarding and destroying medications, dated 12/09/25, required that disposal of controlled substances occur immediately and no longer than three days after discontinuation. Resident #8, admitted with diagnoses including epilepsy, acute respiratory failure, and dysphagia, had a physician’s order for Lacosamide 100 mg tablets via PEG tube twice daily from 11/28/25 through 12/28/25. The medication was therefore discontinued on 12/28/25. On 02/26/26, the Administrator provided a list of residents currently prescribed and taking Lacosamide, and Resident #8 was not on that list. During a medication cart audit on Unit 2 East the same day, an LPN and the surveyor found 23 Lacosamide 100 mg tablets for Resident #8 stored in the narcotic box, despite the medication having been discontinued for 59 days. The LPN stated they did not know why the resident still had the medication and confirmed the resident was not receiving it. In a subsequent interview, the DON acknowledged that monthly cart audits were supposed to be done at the beginning of each month, was unsure if one had been done for January, and was not aware that Resident #8’s Lacosamide tablets were still on hand. As a result, the controlled substance was not disposed of within the timeframe required by facility policy.
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