Controlled Medication Reconciliation Failure
Summary
The facility failed to have an effective medication reconciliation system in place for controlled medications for 3 residents. Resident 8 had diagnoses including dementia and adhesive capsulitis of the right shoulder, and the MDS indicated moderately impaired cognition and impaired ROM in both upper and lower extremities. Resident 48 had diagnoses including dementia and a wedge compression fracture of the fourth lumbar vertebra, and the MDS indicated a short-term memory problem, moderately impaired cognitive skills for daily decision making, and dependence with all ADLs. Resident 49 had diagnoses including dementia and breast cancer, and the MDS indicated moderately impaired cognition. For Resident 8, the narcotic record showed lorazepam 1 mg was removed from controlled storage for administration, but the MAR for that same dose was not signed-marked as administered. For Resident 48, the narcotic record showed acetaminophen with codeine 300-30 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. For Resident 49, the narcotic record showed alprazolam 0.25 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. During interview, the DON stated the facility did not have a system in place where the MARs were reconciled with the narcotic records and had not investigated the controlled medications that were not accounted for. The DON also stated that signing the MAR indicated the resident received the medication and described the process for controlled medications as requiring licensed nurses to remove the medication, sign the narcotic record, and then sign the MAR once the medication was administered. The facility policy required an accurate reconciliation of controlled drugs and documentation of administration on the accountability record and MAR.
Plan Of Correction
F0755 CFR(s): 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records Root Cause: The root cause of the deficient practice was inconsistent adherence to controlled substance documentation and reconciliation processes, including failure to consistently verify Narcotic Records (NR), Medication Administration Records (MAR), and physical counts, along with lack of a standardized discrepancy resolution process and oversight. The corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/13/2026, for Residents #8, #48, and #49, the Director of Nursing (DON) and designee completed a full reconciliation of Narcotic Records (NR), Medication Administration Records (MAR), and physical controlled substance counts. Documentation was reviewed, staff were interviewed, and all narcotic counts were verified to ensure accuracy. Any discrepancies identified were immediately investigated and resolved. No adverse resident outcomes were identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/31/2026, the DON and designee conducted a 100% audit of all residents receiving controlled medications over the past 30 days, verifying: NR documentation accuracyMAR documentation accuracyPhysical count reconciliationCompletion of required signaturesNo additional unresolved discrepancies were identified. Any discrepancies, if identified, would be immediately investigated, reconciled, and documented, with staff re-education provided. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic controls:Standardized Reconciliation Process: Controlled substance counts will be completed at every shift change by two licensed nurses, verifying: Narcotic Record (NR) Medication Administration Record (MAR) Physical count of controlled medications Both nurses must sign and verify accuracy at each shift change. Real-Time Documentation Requirements: All controlled medications must be documented immediately at the time of removal, administration, waste, or return. Documentation must include date, time, dose, balance remaining, and two licensed nurse signatures for waste. Discrepancy Process: Any discrepancy will be identified immediately and investigated at the time of discovery. The licensed nurse will notify the DON/designee immediately. A discrepancy report will be completed, including documentation of findings and resolution. If diversion is suspected, the facility will initiate escalation procedures, including Administrator notification, Consultant Pharmacist involvement, and reporting per facility policy and regulatory requirements. Education & Oversight: On 3/30/2026, the DON conducted mandatory in-service training for licensed nurses on controlled substance procedures, reconciliation, and documentation requirements. The Consultant Pharmacist will provide ongoing monthly review and oversight of controlled substance practices. How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for controlled substance reconciliation and documentation. Monitoring Plan: The DON or designee will conduct weekly audits of a minimum of 5 residents receiving controlled medications for 4 weeks, followed by monthly audits for 2 months. Audits will include: NR vs MAR vs physical count reconciliation Completion of shift-to-shift narcotic count documentation Presence of required signatures Review of discrepancy identification, documentation, and resolution Corrective Action Loop: Any identified noncompliance will be corrected immediately, including reconciliation of counts and documentation updates. The responsible staff member will receive re-education prior to the end of the shift. A follow-up audit within 24 hours will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the Administrator and DON during the monitoring period. The Consultant Pharmacist will review findings during monthly pharmacy reviews. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Shift-to-shift narcotic counts, real-time documentation, discrepancy identification Director of Nursing (DON)/Designee: Oversight, audits, investigation of discrepancies Consultant Pharmacist: Monthly review and compliance oversight Administrator: Oversight and escalation if needed Completion Date: 4/13/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure accurate pharmaceutical services for two residents and related medication storage and recordkeeping. An LPN administered a resident’s insulin glargine pen without priming it first, and a controlled medication log for another resident’s hydrocodone-acetaminophen did not match the blister pack count. In addition, a controlled substance reconciliation log for a medication aide cart had been signed before shift change, and an expired IV tubing supply was found in the LTC medication room.
Medication Error Not Investigated or Documented: The facility failed to investigate, document, and address a reported Zepbound medication error for a resident with moderate cognitive impairment and multiple diagnoses. The event report noted a wrong dose, but the record contained no clear explanation of what occurred, no documented root cause investigation, and no documented actions taken; the DON and RN both stated the process was incomplete, and the consultant pharmacist noted the expected documentation and follow-up for medication errors.
Controlled medications were not properly tracked because the narcotic accountability sheets in one medication cart had multiple entries without the required signatures from two nurses. During the audit, RN #1 and the DON both confirmed that two nurses should have signed the narcotic count sheets.
Controlled substance records were not properly maintained for the Hall A and Hall B medication carts because shift-change narcotic count signatures were missing on multiple occasions. LVNs stated that two nurses were not verifying the count by signing the book, and the DON, ADM, and CCN confirmed that missing signatures meant there was no proof the count was completed and accurate. The facility policy required a physical inventory of controlled meds at each shift change by two licensed nurses or an allowed nurse and med aide.
Incorrect Zyprexa Dose Remained Active on MAR: A resident with psychotic disorder and hallucinations had a Zyprexa dose reduced per MD order, but the prior 10 mg order was not discontinued and both the 5 mg and 10 mg doses remained active on the MAR. The MAR showed both doses were administered daily until clarification was entered, and the LVN stated he entered the new order but thought the old order had been discontinued.
A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Pharmaceutical Services and Controlled Substance Recordkeeping Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs and to ensure drug records were in order for two residents, one medication cart, and one medication room. Resident #8 had diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus, and his MDS documented severe cognitive impairment and insulin use. During a medication pass observation, an LVN administered 15 units of Insulin Glargine pen without priming the pen first. The LVN stated priming was important to ensure the pen was working properly and that failure to prime could affect the dose received. Resident #20 had diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica, and her MDS documented severe cognitive impairment and active sciatica. During observation of the nurse cart, the controlled medication log for Hydrocodone-Acetaminophen 7.5-325 mg did not match the blister pack count: the log showed 6 tablets should have been available, but the pack contained 5 tablets. The LVN stated the tablet should be logged out immediately after administration. The facility also observed that the controlled medication reconciliation log for the 500 hall medication aide cart had been signed in advance of the next shift change, and the medication aide stated it should not be signed early because the cart could be taken away and something could go missing. During observation of the LTC unit medication room, an expired IV tubing supply was found on the shelves with medication equipment and supplies. The LVN stated expired items should not be in the storage room, and the DON and Administrator both stated expired supplies should not be in the medication rooms. The facility policy for insulin pen use required a safety test before each injection, and the controlled medications policy required immediate documentation after administration and a physical inventory at each shift change.
Medication Error Not Investigated or Documented
Penalty
Summary
The facility failed to ensure a reported medication error involving Zepbound for a resident with moderate cognitive impairment and diagnoses including morbid obesity, cerebral palsy, and obstructive sleep apnea was investigated, documented, and addressed in accordance with facility policy. The resident’s event report identified a wrong dose on 4/22/26, but the report did not identify any investigation into the event or any actions taken to prevent further events, and the medical record contained no further information about the incident. During interviews, the DON stated there was a lapse in the process and that an investigation was not completed. The DON reported staff explained the medication did not come from the pharmacy and that the resident did not receive the dose, although the event report stated wrong dose. RN-A also stated there was no documentation explaining what occurred or what actions were taken. The consultant pharmacist stated staff were expected to complete a thorough root cause investigation and analysis, with follow-up and detailed documentation for any medication error, including resident assessment, physician notification when indicated, monitoring for adverse effects, and measures to prevent recurrence. The facility policy stated that when a medication error occurs, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation, or treatment is indicated, and that medication errors are tracked and trended for quality improvement purposes.
Incomplete Narcotic Count Documentation
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion because the facility failed to ensure the narcotic accountability sheets were properly signed by licensed nurses. During a medication cart audit, multiple dates were found on the narcotic accountability sheets without a documented on-coming or off-going licensed nurse signature, including several entries in late April, May, and early June. RN #1 stated that two nurses should have signed the narcotic accountability sheet and had not, and the DON also stated that two nurses should have signed off on the narcotic count sheets.
Missing Controlled Substance Count Signatures on Medication Carts
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for the Hall A and Hall B medication carts. During record review, the narcotic books for both carts were found to have missing signatures documenting shift-to-shift controlled substance counts. On the Hall A medication cart, signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/2026, 1/30/2026, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026. On the Hall B medication cart, signatures were missing on 5/3/2026 and 5/30/2026. During interviews, LVN G and LVN F stated that two nurses were not verifying the narcotic count by signing the book and that, if the count was off, there would be no way to know who to contact or verify that two nurses had counted the medications. The DON stated that when the narcotic book lacks signatures, the count could be incorrect and directly affect the medications the resident receives. The ADM stated missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for residents. The CCN stated that without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. The facility policy required a physical inventory of controlled medications at each shift change by two licensed nurses or an allowed nurse and medication aide, documented on an audit record or accountability record.
Incorrect Zyprexa Dose Remained Active on MAR
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #32 when the facility failed to discontinue an old Zyprexa 10 mg order after the dose was changed to 5 mg in the evening. Resident #32 was admitted with a diagnosis of psychotic disorder with hallucinations and was documented as rarely/never understood with severely impaired cognition. The resident’s care plan addressed psychotropic medication use and gradual dose reduction considerations, and a pharmacy recommendation was made to decrease Zyprexa from 10 mg to 5 mg in the evening, which was signed by the physician on 5/22/2026. The active order summary showed both Zyprexa 5 mg and Zyprexa 10 mg as active, and the MAR showed both doses were administered daily from 5/22/2026 until a clarification order was entered on 6/3/2026. During interview, LVN A stated he received the dose reduction order, notified the hospice provider, entered the new 5 mg order, and thought he had discontinued the 10 mg order, but did not know why it remained active. The DON stated the charge nurse was responsible for entering new orders into the MAR and later obtained clarification from hospice regarding the medication dose.
Failure to Provide Ordered Phosphate Binder
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administration of medications for Resident #59, who was admitted with ESRD, type 2 diabetes mellitus with unspecified complications, depression, anxiety, bipolar disorder, and parkinsonism. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the EMAR showed an order for Sevelamer Carbonate (Renvela) 800 mg, 1 tablet by mouth before meals for disorders of phosphorus metabolism, with a start date of 04/17/2026, but the resident did not receive the medication from 04/18/2026 through 04/30/2026. Further review of the May 2026 EMAR showed the same Renvela order with multiple hold periods, and the resident did not receive any doses during that month. Review of the June 2026 EMAR showed the medication remained on hold and had not been administered from 06/01/2026 through the time of review. The dialysis RD stated the resident was on a fluid restriction and was prescribed Sevelamer Carbonate because of elevated phosphorus, that dialysis and the facility communicated through forms and faxed orders, and that the medication had been filled last on 03/27/2026 and 04/20/2026. Staff interviews revealed the facility believed dialysis normally refilled the medication, but the pharmacy said it could fill it if needed. The DON stated she did not know the resident had gone without the medication and confirmed the facility did not have it readily available even though it should have.
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