F0761

E

Failure to Timely Remove and Dispose of Discontinued Narcotic Medications

Perrysburg, Ohio Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely remove and properly dispose of discontinued narcotic medications, including those for residents who had died or been discharged. Surveyors reviewed records and medication carts and found multiple instances where controlled substances remained in the narcotic drawers after the medications had been discontinued or the residents were no longer in the facility. For one resident who had expired, 15 tablets of Tramadol 50 mg remained in the 100-hall medication cart. Another resident with end stage renal disease, congestive heart failure, and multiple malignancies had 22 tablets of discontinued Tramadol HCL 50 mg still stored in the 300-hall medication cart after discharge.

Additional observations showed that a resident with anxiety, hemiplegia, hemiparesis, and adjustment disorder had 22 tablets of discontinued oxycodone-acetaminophen 10-325 mg remaining in the narcotic drawer. A resident with dementia, schizophrenia, atrial fibrillation, and congestive heart failure who had been transferred out still had 23 tablets of discontinued Tramadol 50 mg in the cart. Another resident with hip fracture, dementia, anxiety, bipolar disorder, and diabetes mellitus who had expired had 29 tablets of Tramadol 50 mg, 31 tablets of lorazepam 0.5 mg, and a full unopened bottle of liquid morphine sulfate remaining in the locked narcotic drawer.

Surveyors also identified that a resident with thoracic vertebra fracture, quadriplegia, contracture, and left shoulder stiffness who had been discharged still had 20 oxycodone-acetaminophen 5-325 mg tablets in the narcotic drawer, and a resident with Alzheimer’s disease, dementia, chronic kidney disease, and peripheral vascular disease who had expired under hospice care had 28 lorazepam 0.5 mg tablets and an unopened bottle of morphine sulfate concentrate remaining in the cart. A resident with migraine, osteoarthritis, heart disease, and Parkinsonism who had discharged to another LTC facility still had 22 Percocet 10-325 mg tablets in the narcotic drawer, despite active orders having been discontinued or the resident no longer being present. LPNs confirmed that these residents were no longer in the facility and that their narcotics remained in the medication carts, and the Interim DON acknowledged awareness that expired narcotics remained in the carts. Facility policy stated that discontinued controlled substances were to be removed from patient care areas and temporarily stored in a securely locked area until destruction, which was not followed in these cases.