F0755

D

Failure to Reconcile and Account for Controlled Medication in Narcotic Refrigerator

Lubbock, Texas Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective system for acquiring, receiving, dispensing, administering, and reconciling controlled medications, specifically Lorazepam Oral Concentrate 2 mg/mL prescribed for one resident. The resident was an adult male admitted with diagnoses including unspecified diastolic congestive heart failure, acute respiratory failure, acute kidney failure, and generalized anxiety disorder. An order dated 03/18/2026 directed that 0.25 mL of Lorazepam oral concentrate be given by mouth every four hours as needed for anxiety, and the pharmacy shipment summary showed that a 30 mL bottle of this medication was delivered to the facility on that date. The Medication Administration Record from 03/18/2026 through 03/31/2026 showed no administrations of this PRN medication during that period.

The Administrator reported that on 03/24/2026, following an audit of narcotic medications conducted by the DON and nursing staff, the prescription box for the resident’s Lorazepam was found in the narcotics refrigerator, but the bottle of medication was missing. Interviews with multiple LVNs revealed inconsistent practices regarding narcotic counts, particularly for medications stored in the narcotic refrigerator. Some LVNs stated they counted only the PRN narcotics on the medication carts and did not count the narcotics in the refrigerator, while others stated they believed they were counting all narcotics, including those in the refrigerator. One LVN, who assisted with the narcotic audit, stated that when she removed all items from the narcotic refrigerator, she discovered an empty box labeled for the resident’s Lorazepam without the corresponding bottle inside, and a subsequent search did not locate the medication.

Further record review and interviews showed that the facility lacked completed narcotic count sheets for the period from 03/18/2026 to 03/24/2026, despite a policy requiring controlled substances to be reconciled upon receipt, administration, disposition, and at the end of each shift. The DON acknowledged that the narcotic refrigerator was not being consistently counted and that there was no specific system in place to ensure it was included in shift-to-shift reconciliations. The facility’s written policy and the Narcotic Book/EMAR Verification Sheet required that at each shift change both nurses verify all scheduled and PRN narcotics, document the actual number of cards, bottles, and patches, and turn in the form and any empty cards or bottles to the DON every shift without exception. The absence of narcotic count documentation for the relevant dates, combined with staff reports that the refrigerator narcotics were not always included in counts, led to the discovery that the resident’s newly received Lorazepam bottle was missing and could not be reconciled.