F0755

E

Failure to Reconcile and Secure Controlled Medications on 4th Floor Carts

Flint, Michigan Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate reconciliation and secure handling of controlled medications on the 4th floor medication carts. During a narcotic count on the 4th floor East cart, the Unit Manager identified that a blister pack of Lorazepam 0.5 mg, ordered every 4 hours as needed for anxiety, contained only 5 tablets when the narcotic sign-off sheet documented 7 tablets on hand the previous day. The discrepancy of 2 tablets was confirmed by the Unit Manager, who verified that the written inventory did not match the actual blister pack count. When questioned, the nurse assigned to the resident stated she was planning to document the administrations, and the Unit Manager stated that nurses are required to sign for medications as soon as they are administered.

Additional deficiencies were identified in the reconciliation of controlled substances on both the East and West 4th floor medication carts. Review of the West cart’s controlled substance inventory for a specific morning shift showed only one nurse’s signature instead of the required two signatures from the outgoing midnight nurse and incoming day nurse; the nurse who signed confirmed that the midnight nurse had left the building early and did not return, and she did not know with whom she had counted the narcotics. For the East cart, the February controlled substance shift inventory form showed no entry for the morning change of shift on the same date, indicating that no narcotic count was performed at that time. Employee records showed that the midnight nurse left the facility at 4:19 AM while responsible for 41 residents and gave the medication cart keys to a non-licensed staff member instead of directly to another licensed nurse, and the scheduled 6:00 AM medication pass was not completed as required.