F0755

D

Incomplete Reconciliation and Documentation of Controlled Medications

Indianapolis, Indiana Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The facility failed to ensure controlled medications were accurately reconciled during delivery and properly documented on pharmacy delivery slips and controlled drug records for three residents. For one resident, a pharmacy delivery slip dated 1/8/26 showed that 40 tablets of oxycodone/acetaminophen 10/325 mg were delivered, but the spaces for "Received By," "Delivery Date/Time," and "Print Name" were left blank. The corresponding Controlled Drug Record for the same prescription and date also lacked entries for the starting balance, the nurse who checked in the medication, and the date, and no tablets were signed out as administered on that record.

For a second resident with diagnoses including paraplegia, diabetes, and anxiety, a Narcotic Administration Record covering a period from late January to mid-February for oxycodone/acetaminophen 5/325 mg showed that the spaces for "Checked in By" and "Date" were left blank. A subsequent Narcotic Administration Record for a new prescription of the same medication also had the "Starting Balance" field left blank. For a third resident with dementia, epilepsy, and cognitive communication deficit, a Controlled Drug Record for hydrocodone/acetaminophen 5/325 mg similarly lacked entries for "Checked in By" and "Date." During interview, an LPN stated that the pharmacy delivery slips and controlled drug records for these residents should have been completed in full by the nurse receiving the medications, and the facility’s policy required checking the delivery manifest at the time of delivery and signing with name, date, and time if correct.