Failure to Accurately Account for and Properly Dispose of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate system for disposition and accounting of controlled medications and to ensure staff competency in these processes. During medication pass on one hall, a medication aide (MA A) reported she had never experienced a resident refusing narcotics or controlled medications, but stated that if a resident refused, she would waste the medication directly into the sharps container on her cart, with or without a witness. She stated she did not think a witness was needed and was unsure of the risk of wasting without a witness. MA A also stated that the controlled medication count sheet should always be documented immediately after administration to prevent forgetting and causing a discrepancy, and reported she had not received in‑service training on controlled medication counting and disposal since starting work in September 2025. On another hall, observation of a medication cart managed by a second medication aide (MA B) revealed a discrepancy between the Lorazepam card and the controlled drug count sheet for one resident: the medication card showed 18 tablets while the count sheet showed 19. MA B stated he had administered Lorazepam to the resident earlier that morning but forgot to document the count sheet immediately because he became busy, and acknowledged that failure to document right away could lead to suspicion of drug diversion. The resident confirmed receiving all medications that morning and did not notice any missed dose, and the MAR reflected Lorazepam administration at 0700. Other staff, including an LVN and the DON, described facility expectations that controlled medications be wasted only with a witness, using a drug buster rather than a sharps container, and that count sheets be updated as soon as a controlled medication is removed from the cart. Facility policy required two licensed or registered personnel to document destruction of medications and to dispose of medications in a manner that renders them unusable.
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