F0755

E

Controlled substance documentation, reconciliation, and handling failures

Perry, Iowa Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

Facility staff failed to accurately document the administration of controlled substances, including morphine and lorazepam, on both the controlled substance records and the electronic Medication Administration Record (MAR/EMAR) for multiple residents. For one resident with cerebrovascular accident, hemiplegia, chronic pain, and hospice status, staff frequently administered liquid morphine 0.25 ml sublingually every 2 hours PRN for pain or shortness of breath and lorazepam 0.5 ml PO every 2 hours PRN for restlessness or anxiety. However, numerous doses of lorazepam were signed out on the controlled medication record but not recorded on the MAR, and other doses were documented on the MAR but not signed out on the controlled substance record. For the same resident, large numbers of liquid morphine doses were signed out on the controlled medication utilization record but not documented on the MAR, and there were multiple mathematical and transcription errors in the running counts, including repeated remaining amounts, over-subtraction, and unaccounted volume discrepancies. These documentation failures led to an apparent shortage of 1.5 ml of morphine when the bottle was empty but the count showed medication remaining, and an internal investigation later identified multiple transcription and subtraction errors and mismatches between the paper administration record and the EMAR.

During a narcotic count observation with a certified medication aide, the surveyor identified additional discrepancies involving another resident’s tramadol 50 mg in a bubble pack. The bubble pack showed 6 tablets remaining while the controlled medication utilization record showed 8 tablets remaining. The aide stated she had just given the medication and had not yet signed it out on the controlled medication form, then entered two doses on the controlled medication form and later documented the administration in the EMAR hours after the actual administration time. For the same narcotic count, the surveyor also noted a discrepancy on the liquid morphine record for the hospice resident: a dose was signed out with an amount remaining of 29.75 ml, which was then crossed off and changed to 30 ml under the “wasted” column without initials or explanation. These findings showed that staff did not consistently sign out controlled substances at the time of administration and did not maintain clear, accurate, and contemporaneous controlled substance records as required by facility policy.

The facility also failed to ensure proper handling and disposal of medications during administration. For a resident with hypertension, pain, and depression, a certified medication aide prepared multiple oral medications from bubble packs and delivered them to the resident. The resident noticed that one yellow pill was missing, and the aide returned to the cart, found the partially punched bubble pack, and pushed the pill out, causing it to fall onto the top of the medication cart. Instead of discarding the dropped pill, the aide swept it across the cart surface into a medication cup and then administered it to the resident. The administrator reported that if a pill was dropped on the medication cart, staff could ask the resident if they were okay with taking it or otherwise destroy the pill and obtain a new one, while the former DON stated she expected staff to waste any dropped medication. Additionally, the facility failed to destroy a controlled substance (lorazepam) after 90 days, as the controlled medication record showed a 30 ml bottle received and used beyond 90 days before the remaining 13 ml was destroyed.

For another resident with diabetes, arthritis, stroke with hemiparesis, and chronic pain, the facility failed to complete and retain a narcotic administration record and reconciliation for a shipment of Morphine Sulfate ER 15 mg tablets. The MAR directed staff to administer Morphine Sulfate ER 15 mg three times daily and Morphine Sulfate 15 mg every 12 hours PRN for chronic pain, and a shipment summary confirmed that 30 tablets of Morphine Sulfate ER were delivered. However, the clinical record lacked a narcotic administration record and reconciliation for this controlled substance, and facility leadership confirmed that the narcotic administration record for this delivery could not be located. The facility’s controlled substances policy required that controlled substances be counted upon delivery, documented on a designated controlled substance record, and that an individual resident controlled substance record be created for each resident receiving a controlled substance, but this process was not followed or the documentation was not retained for this resident’s Morphine ER.