Failure to Reconcile and Account for Controlled Substances After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and properly account for controlled substances after residents were discharged. During a medication cart storage observation on the Birch unit with the DON, surveyors found a card of Hydrocodone-Acetaminophen 5-325 mg containing 30 tablets for resident R67 stored in the narcotic box with its individual controlled inventory sheet attached to the card rather than maintained in the cart’s controlled inventory binder. The DON stated that R67’s inventory sheet was not kept in the binder for counting because the resident had been discharged. Record review showed R67 had an as-needed order for Hydrocodone-Acetaminophen that started on 12/03/2025 and was discontinued on 12/08/2025, and the EMR documented that R67 was discharged on 12/16/2025. In the same observation, the Birch unit medication cart also contained a card of Alprazolam 0.25 mg with 14 tablets and a card of Tramadol HCL 50 mg with 15 tablets for resident R68 stored in the narcotic box, each with individualized controlled inventory sheets attached to the cards instead of being in the narcotic binder. The DON explained that R68’s inventory sheets were not maintained in the binder for count because the resident had also been discharged, and stated that individual controlled count sheets should be in the narcotic binder so all stored narcotics are accounted for during shift-change counts and that narcotics should be destroyed per policy when a resident discharges. EMR review showed R68 was discharged on 12/20/2025 and had as-needed orders for Alprazolam 0.25 mg and Tramadol HCL 50 mg. The facility’s controlled substances policy required nursing staff to count controlled medication inventory at the end of each shift using narcotic records to reconcile counts and to monitor and reconcile controlled substance inventory to identify loss or potential diversion.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.