Failure to Reconcile and Secure Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled substances were reconciled and stored in accordance with its own policies and accepted professional standards. The facility’s Medication Storage policy requires Schedule II drugs and back-up stock of Schedule III–V medications to be stored under double lock and key, and Schedule II medications stored in the same area as other medications (such as in a refrigerator) to be kept in a separately locked, permanently affixed compartment. The Controlled Substance Administration and Accountability policy requires that all controlled substances obtained from a non-automated cart or cabinet be recorded on a designated usage form, and that in areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite these policies, surveyors observed multiple deviations during medication cart and storage reviews. During reconciliation of the west wing medication cart with a registered nurse, a taped prescription bottle of hydrocodone-acetaminophen 7.5 mg/325 mg for one resident was found; the nurse stated she did not open the taped bottle to count the remaining pills, acknowledged she could not see how many pills were inside, and noted that the tape could be removed and reapplied without detection. She also stated that the resident was no longer receiving the dose in that bottle. In the medication room, two plastic containers holding Schedule II–V stock medications were observed sitting on top of a small refrigerator, and the nurse confirmed these were not in an affixed locked cabinet, despite the facility’s control box inventory including multiple opioids, benzodiazepines, and other controlled substances. On the north medication cart, another registered nurse retrieved a resident’s lorazepam 2 mg/mL from an unlocked storage closet, looked only at the box, and returned it to the refrigerator without opening the box to check the bottle; this nurse stated that all staff had access to the refrigerator in the stock room and that the stock room was not continuously visible, making it possible for someone to remove the refrigerator. At the time of the survey, the midnight census documented 82 residents residing in the facility.
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