F0755

D

Failure to Maintain Accurate Controlled Substance Count for Lorazepam

Petersburg, Illinois Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate reconciliation and accounting of a controlled substance for one resident receiving Lorazepam concentrate. The facility’s written policy dated 5/30/2017 requires that controlled medications be counted between shifts or whenever there is a change in nurses, that each controlled medication received from the pharmacy be counted and a count sheet initiated by a nurse, and that all shortages or overages be reported immediately to the DON and pharmacist on call. For this resident, the Controlled Drug Receipt Record/Disposition Form dated 1/2/2026 documented an order for Lorazepam concentrate 2 mg/mL, 0.5 cc (1 mg) PO every 2 hours as needed, and showed that only 2 mL remained as of 3/26/2026.

However, on 3/25/2026 at 1:10 PM, observation and confirmation by an RN showed that the Lorazepam bottle actually contained 12 mL, which was significantly more than the 2 mL documented on the controlled drug record. The RN stated that she continued to deduct doses from the bottle based on the sheet, despite the visible discrepancy between the recorded amount and the actual volume in the bottle. On 3/26/2026 at 2 PM, the Administrator confirmed that the Lorazepam concentrate for this resident was over by far too much and that nursing staff continued to sign off on the controlled drug record even though the amount in the bottle was far greater than what was being recorded, demonstrating a failure to ensure the narcotic count was correct in accordance with facility policy.