F0761

J

Unsecured Controlled Medications Allowed Resident Access and Overdose

Topeka, Kansas Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to secure medications and keep them inaccessible to residents. Pharmacy records showed that a delivery including three bags of medications (one white, one blue, and one red) arrived in the evening, with the red bag containing 90 tablets of alprazolam and 90 tablets of lorazepam. Licensed Nurse G signed for the medications, placed the bags on a chair in the nurse’s station, and left them there without securing them in a locked compartment. Video footage later confirmed that the nurse’s station was left unattended with the medication bags still present on the chair.

While the nurse’s station was unmanned, two residents were observed outside the area. One resident entered the unsupervised, unsecured nurse’s station, took drinking cups and other items, and then, at the direction of the other resident, took the red bag of medications from the chair and left the nurse’s station. The resident who directed this action later took the red bag back to his room. At an unknown time, he ingested 14 tablets of alprazolam and 18 tablets of lorazepam. Subsequent discovery of pill cards hidden in a paper towel dispenser showed that some of the alprazolam and lorazepam tablets remained, but a portion of each medication was missing, consistent with the amounts the resident reported taking.

The resident who ingested the medications had documented diagnoses of schizophrenia, anxiety, suicidal ideation, and major depressive disorder, with a recent MDS indicating intact cognition but severe depression, hallucinations, delusions, and rejection of care. His care plan documented trauma-related distress, hallucinations, substance use that exacerbated suicidal thoughts, and intermittent passive suicidal ideation, with directions for staff to assess for suicidal ideation, intent, and plan each shift, especially at night. In the early morning hours after the ingestion, nursing notes documented that the resident was lethargic, staggering, had slurred speech, and then experienced repeated episodes of dark vomiting, short labored breaths, incoherent speech, and lethargic behavior, leading to transfer to the hospital where he was intubated and later diagnosed with pneumonia and fever secondary to suspected aspiration of fluid into his lungs. The facility’s own policies required that all drugs and biologicals be stored in a safe, secure manner and that resident safety, supervision, and assistance to prevent accidents be a facility-wide priority, but the medications were not secured and the nurse’s station was left unattended, allowing residents access to controlled substances.

Further documentation and witness statements highlighted conflicting accounts regarding who was responsible for putting away the delivered medications. LN G stated he had set the medications aside on the overflow medication cart to be put away later and that a Certified Medication Aide later put them away, while the CMA stated she never received a handoff of medications from LN G and only found and stored the white and blue bags, not any controlled substances or a red bag. The facility’s incident report and administrative review confirmed that the controlled substances for two other residents were missing from the medication supply, that the pharmacy delivery forms and controlled substance count sheets could not initially be located, and that the missing narcotics were later found hidden in a paper towel dispenser in a resident’s room. Subsequent observation by the surveyor also showed that the nurse’s station could be accessed by reaching over and unbolting the inside barrel bolt lock, and that a resident was present at the counter while the station was unattended, further demonstrating that medications and staff work areas were not consistently secured from resident access.