F0755

E

Failure to Accurately Document and Reconcile Controlled Medications

Roanoke Rapids, North Carolina Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately document and reconcile controlled medications for multiple residents, and to follow its system for accounting for controlled substances between shift changes and upon receipt or removal from locked storage. For one resident with metastatic cancer, open malignant wound, neuropathy, and a history of spine surgery, hydrocodone-acetaminophen and oxycodone orders were in place for pain management. The hydrocodone-acetaminophen controlled drug record showed 11 removals from storage, while the MAR reflected only one administered dose. The oxycodone controlled drug record showed 13 removals, while the MAR reflected 11 administered doses. Several nurses signed out controlled medications without corresponding MAR documentation, left times blank, or misdated removals. One nurse reported he arrived late for his shift, did not believe a narcotic count was done at shift change, and later signed out additional doses without times to correct an off count, intending another nurse to fill in the times. Another nurse admitted she often became busy and forgot to document administrations on the MAR after removing doses from storage, and another nurse stated she administered a dose but forgot to sign the MAR.

The facility’s unit-level controlled substance count sheets also showed multiple deficiencies in reconciliation practices. On one unit, over a period of several days, the controlled substance count sheet documented 20 instances where medication cards were added to or subtracted from the total count. For 11 of these, only one nurse’s signature was present, and for seven there were no nurse signatures at all. In two instances, there was only a notation of “+1” without any information about which medication, which resident, or which nurse was involved. Across multiple days and shifts, required signatures of off-going or on-coming nurses were missing, the number of cards/containers and count sheets was left blank, and there were gaps of up to 36 hours with no documented count or reconciliation. The DON later reported that a count had been reconciled in her presence during one of these undocumented periods, but this reconciliation was not reflected on the count sheet.

For another resident with chronic pain receiving Oxycontin twice daily, discrepancies existed between the pharmacy’s records and the facility’s records regarding dispensed and returned doses. The pharmacy’s system showed that 28 Oxycontin tablets were dispensed on one date, that 17 doses from that fill were returned the following day, and that another 28 tablets were sent on the same day as the recorded return. The pharmacist stated they had no record of returned Oxycontin from the later dispense and were still awaiting unused doses. In contrast, the facility’s controlled drug records showed all 28 doses from the first fill were used with none returned, and that 17 doses from the second fill remained after discharge and were returned on a later date. The Corporate Nurse Consultant stated that the facility’s return documentation was pulled directly from the pharmacy’s system and could not explain why the pharmacy’s internal records and the facility’s records could not be reconciled.

A third resident with vertebral osteomyelitis and low back pain had orders for scheduled Oxycontin and PRN oxycodone. For this resident, the March MAR and Oxycontin controlled drug record did not consistently match. On one date, a nurse initialed the 10:00 AM Oxycontin dose as given on the MAR, but no corresponding removal was documented on the controlled drug record; the nurse later stated she had not administered the dose because the resident appeared sedated, and that she had signed the MAR before deciding to hold the dose and did not know how to correct the entry. On another date, a nurse documented administration of PRN oxycodone and placed initials with an asterisk and the comment “RC” by the 10:00 PM Oxycontin dose, but no Oxycontin removal was documented; the nurse later stated she had not realized the resident had Oxycontin ordered, gave oxycodone instead, and did not document an explanation for not giving the Oxycontin. On a separate date, another nurse initialed the 10:00 AM Oxycontin dose as administered on the MAR, but there was no corresponding removal on the controlled drug record, and the nurse could not recall why the documentation did not match. The DON stated she expected removal documentation from locked storage to coincide with MAR documentation of administration.