Failure to Accurately Account for Controlled Substances Across Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s management and accounting of controlled substances, as required by its policy and state regulations. The facility’s controlled substances policy, last reviewed on 9/1/25, stated that controlled substance inventory is to be monitored and reconciled to identify loss or potential diversion in a timely manner. However, review of multiple residents’ March 2026 Medication Administration Records (MARs) and corresponding Controlled Drug Records showed repeated instances where controlled medications were signed out but had no corresponding documentation of administration on the MAR. For one resident with an order for oxycodone 10 mg scheduled every morning and every six hours as needed, three PRN administrations were documented on the MAR, but six additional oxycodone doses were signed out on the Controlled Drug Record without matching MAR entries. Another resident with an order for Tramadol 50 mg every six hours as needed had no administrations documented on the MAR, yet two doses were signed out on the Controlled Drug Record. A third resident ordered oxycodone 5 mg every six hours had seven administrations documented on the MAR, while nine additional doses were signed out without corresponding MAR documentation. A fourth resident with an order for oxycodone 5 mg every six hours as needed had five administrations documented, but thirteen additional doses were signed out without matching MAR entries. Similar discrepancies were found for seven additional residents. One resident ordered oxycodone 5 mg every six hours as needed for moderate pain had eight administrations documented, but sixteen more doses were signed out without MAR documentation. Another resident with orders for oxycodone 5 mg for moderate pain and 10 mg for severe pain had four 5 mg administrations documented, while four additional doses, including a 10 mg dose signed out but documented as 5 mg on the MAR, lacked accurate or corresponding MAR entries. Other residents with PRN orders for Tramadol, oxycodone, or hydrocodone/acetaminophen had one to three administrations documented on their MARs, yet multiple additional doses were signed out on Controlled Drug Records without matching MAR documentation. During an interview, the Nursing Home Administrator and Interim Director of Nursing confirmed that the facility failed to ensure controlled substances were accurately accounted for for eleven of sixteen residents reviewed.
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