Improper Disposal and Documentation of Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of controlled substances in accordance with its own Controlled Drug Handling, Reconciling, Count Discrepancy, & Disposal Policy and Procedure dated 5/30/2017. The policy requires that CII–CV controlled drugs be destroyed by two licensed staff and that records of destruction include the medication name, strength, quantity destroyed, patient name, prescription number, and both signatures and dates destroyed. Review of controlled drug receipt/ disposition records showed multiple instances where controlled medications were documented as dropped or wasted without evidence of proper destruction or complete documentation. For one resident with an order for Morphine Sulphate IR 30 mg every six hours, the record showed entries on two dates by an agency RN indicating “dropped/wasted.” Another resident with an order for Lorazepam 0.5 mg twice daily had an entry documented as “dropped” by the same agency RN. Additional controlled drug records showed similar issues for three more residents. One resident with an order for Oxycodone/APAP 5/325 every eight hours had two separate entries documented as “dropped/wasted” by the same agency RN. Another resident with an order for Hydrocodone/APAP 5-325 mg every six hours as needed had an entry documented as “dropped” by an unidentified nurse. A fifth resident with an order for Hydrocodone/APAP 7.5/325 mg five times daily had a record showing one pill taken with no date, no time, and no nurse signature. In an interview, the Administrator stated she became aware of multiple controlled drug record issues after an agency RN contacted her about medications being packed incorrectly and, upon conducting a house audit, she realized that improper discarding of controlled substances was not an isolated incident. She confirmed that nursing staff were not discarding controlled substances correctly.
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