F0761

D

Improper Disposal and Lack of Witnessing for Controlled Substance Waste

Bellbrook, Ohio Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to improper disposal of a controlled substance for one resident with moderately impaired cognition and multiple medical diagnoses, including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. During a morning medication pass, an LPN removed a 150 mg pregabalin capsule from a locked medication cart drawer, signed it out in the narcotic tracking binder, opened the capsule, and poured the contents into a medication cup for administration. The resident subsequently refused the pregabalin along with all other morning medications offered.

After the refusal, surveyors observed that the facility had no waste/disposal solution available to safely discard pregabalin powder or other controlled substances, and staff were unable to locate any such solution. The DON stated that a regional director would need to obtain a disposal solution from another facility and, in the meantime, instructed the LPN to dispose of the pregabalin and other refused medications by flushing them down the toilet. The LPN then entered an empty, unassigned room and flushed the controlled substance without another staff member present to witness the disposal. The DON later confirmed that disposal of controlled substances should be witnessed by another licensed nurse, and facility policy and the cited Ohio Administrative Code require controlled substances to be disposed of in accordance with applicable regulations and with appropriate witnessing by licensed nursing staff.