Failure to Maintain Accurate Controlled Substance Accountability
Penalty
Summary
The facility failed to maintain accurate records of usage and accountability for controlled substances on one of six medication carts for two residents. During a narcotic reconciliation count conducted at 10:21 AM, surveyors found that one resident’s Controlled Drug Administration Record Sheet documented seven tablets of lorazepam 2 mg available, while the corresponding blister card contained only six tablets. For a second resident, the Controlled Drug Administration Record Sheet documented twenty-nine tablets of clonazepam 1 mg, but the medication card contained twenty-eight tablets. These discrepancies showed that the documented counts on the controlled drug administration records did not match the actual number of tablets present in the blister cards. At 10:33 AM, the LPN responsible for the medication cart stated that they had administered the first resident’s medication around 7:45 or 8:00 AM and the second resident’s medication around 8:15 AM, and acknowledged that they were trying to hurry with the morning medication pass and believed they would sign out the narcotics after administration. At 11:10 AM, the Assistant Director of Nursing stated that after a nurse administers medication, they are required to immediately sign out that medication on the appropriate documents, and that controlled substances must be signed out on the controlled medication sheet for quick reference and accountability. Facility policy on controlled substances and medication pass, dated August 2020 and July 2025 respectively, requires controlled medications to be securely stored, counted at each change of custody, and documented immediately after administration, which did not occur in these instances.
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