Improper Storage and Undocumented Disposition of Discontinued Medications
Summary
The deficiency involves the facility’s failure to properly dispose of or return discontinued, unused, or leftover medications following resident death, discharge, or changes in medication regimens. Surveyors found that for three residents, the facility could not provide documentation that medications were either destroyed or returned to the pharmacy as required by policy. The facility’s own self-reported incident indicated that an anonymous complaint to the corporate compliance office alleged theft of resident medications, and the subsequent internal investigation identified concerns with how discontinued medications were handled and stored. The facility had recently changed from one pharmacy provider to another, and medications were supplied both via an automated dispensing system and blister-pack cards, with narcotics stored under double lock in medication carts and other medications in a locked medication room. Interviews with multiple staff revealed that discontinued medications, including narcotics, were routinely stored in the DON’s office rather than being promptly destroyed or returned. The former ADON reported that when residents were discharged or had medication changes, the former DON placed these medications in an unlocked cupboard in her office, a practice that had been ongoing for two to three years. She stated there had been at least 30 medications in that cupboard and that the former DON said they might as well keep them since they would not receive pharmacy credit. The ADON and other staff reported that the former DON gave medications from this cupboard to staff who did not have insurance and discussed helping a family member with these medications. Staff also reported that discontinued narcotics were kept in a locked drawer of the DON’s desk without any inventory or shift-to-shift count, and that only the DON had the key until the HR Manager accessed the desk during the DON’s vacation and found multiple medications, including narcotics. The review of clinical records and pharmacy documentation for specific residents showed missing evidence of proper medication disposition. One resident who was admitted and later died at the facility had multiple medications dispensed in blister-pack form by both pharmacies, including atorvastatin, pantoprazole, warfarin, bumetanide, carvedilol, and hydroxyzine; the facility could not produce documentation of destruction or pharmacy invoices showing return of these medications after the resident’s death. Another resident who was admitted and later discharged had lidocaine 5% patches dispensed, but the facility could not provide documentation of destruction or return after discharge. A third resident, admitted and later discharged home, had several medications dispensed by the second pharmacy (bumetanide, glipizide, lisinopril, apixaban, and oxybutynin), and the facility could not provide pharmacy invoices documenting their return. Interviews with pharmacy representatives clarified that, contrary to some staff beliefs, blister-pack medications could be returned for credit under certain conditions, and facility policies required that discontinued medications be removed from active use, stored in a separate locked area, and either returned or destroyed with appropriate documentation and witnesses. These findings collectively demonstrate that the facility did not follow its own policies and applicable standards for the secure storage and disposition of discontinued and leftover medications. Additional staff interviews further detailed the inconsistent and improper handling of discontinued medications. One LPN stated that there was a tote in the medication room where discontinued medications were placed and that, because the pharmacy often refused returns, nurses used a Drug Buster system to destroy them. However, other staff consistently described the presence of approximately 20–30 discontinued medications in the DON’s office cupboard and narcotics in the DON’s desk drawer. The HR Manager confirmed that, during the DON’s vacation, he unlocked her desk to retrieve personnel paperwork and observed at least 20 different medications in the drawer, and he reported this to the Administrator. The Administrator acknowledged that the corporate investigation confirmed medications were stored inappropriately in an unlocked cupboard in the DON’s office and that the DON had given a CNA one of these medications, which the CNA later returned during the investigation. The Administrator also stated that narcotics found in the DON’s desk included a blister-pack card and a used bottle of liquid morphine with an unknown remaining amount, and that it was not appropriate for the DON to keep narcotics in her desk. Facility policies in effect required all drugs and biologicals to be stored in locked compartments, controlled substances to be secured under double lock, discontinued medications to be removed from active use and stored in a separate locked area, and all destruction or return of medications to be documented with appropriate witnesses, which did not occur in these instances. Pharmacy representatives provided additional context that contrasted with staff practices and beliefs. A nurse consultant from the second pharmacy stated that medications should be returned to the pharmacy when discontinued or when a resident is discharged, except for narcotics, topicals, inhalers, accessed vials, or other non-returnable items, and that returns had to occur within a specified time frame to receive credit. A representative from the first pharmacy stated that the state was a no-return state for credit, while another LTC pharmacist consultant clarified that facilities could return blister-pack medications for credit even if some doses had been used, as long as the remaining doses were sealed and intact, and that this was common practice in the state. These statements, combined with the facility’s inability to produce destruction logs or return invoices for the medications associated with the three residents, and the documented storage of discontinued medications and narcotics in the DON’s office and desk, form the basis of the deficiency related to failure to complete proper disposition of medications in accordance with policy and regulation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with COPD, respiratory failure with hypoxia, and sleep apnea had nebulizer treatments documented as complete even though the nebulizer cup still contained medication during observations. Staff found the nebulizer left assembled on the resident’s end table, and an RN and LPN confirmed medication remained in the cup. A self-administration assessment stated the resident was not safe to self-administer inhalants without supervision, but the record was not updated to reflect that change, and the facility’s nebulizer policy required staff to remain with the resident and clean the equipment after use.
The deficiency centers on multiple failures in controlled substance management, including diversion, tampering, and administration of discontinued narcotics. Discontinued Lorazepam, Oxycodone, and Hydrocodone/Acetaminophen remained in controlled substance boxes on med carts instead of being promptly returned to the pharmacy, leading to inaccurate narcotic counts and missing tablets. Several blister packs of Oxycodone and Hydrocodone/Acetaminophen were found taped or perforated, with tablets replaced by Metoprolol, Seroquel, Hydroxyzine, or lower-dose opioids, while declining count sheets and return logs documented that some pills "did not match." A nurse admitted administering Lorazepam and Oxycodone to residents without checking the eMAR, removing doses after the physician orders had been discontinued and without corresponding MAR entries. Staff interviews described discovering taped blister packs and non-matching pills during shift-change narcotic counts, and the DON and regional clinical leadership identified that discontinued controlled substances were not being removed from the carts and returned as required, allowing misappropriation and use of medications without active orders.
Failure to Properly Reconcile and Destroy Controlled Medications: The facility failed to ensure accurate and periodic reconciliation and proper disposal of controlled meds. The DON and Administrator found the double locked drawer for discontinued narcotics full, with the last documented destruction occurring months earlier and only one of six pages in the destruction log containing the required witness signature. The DON stated she had not conducted any narcotic destruction since her hire, and facility policy required disposal of controlled substances within 3 days of discontinuation with two witness signatures.
The facility failed to follow safe medication administration practices by leaving medications unattended at the bedside and not directly observing residents taking them, even though no residents were authorized to self-administer. In multiple instances, an RN and an LPN placed cups of medications on bedside surfaces and left, or medications were found unattended, including for a cognitively intact hospice patient and a resident with ESRD, as well as a resident with severe recurrent MDD with psychotic features and a history of suicidal ideation. Staff acknowledged leaving medications at the bedside as a routine way to encourage ingestion, despite facility policies requiring medications to remain under direct observation during passes and prohibiting unauthorized bedside storage or self-administration.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
The facility failed to maintain accurate clinical records for several residents receiving antihypertensive medications with specific BP and pulse parameters. For multiple residents with vascular dementia, CHF, hypertensive heart disease, and stroke history, the MARs showed blood pressure medications as administered even when recorded vital signs were below ordered hold parameters, and there were no corresponding nursing notes explaining the discrepancies. Staff interviews indicated that CMAs and LVNs report following parameters and sometimes mis-clicking in the electronic MAR, leading to incorrect documentation, while the DON acknowledged there was no process to verify whether medications were actually given or held when vitals were out of range, despite a policy requiring vital sign checks and holding medications per parameters.
Nebulizer Treatment Not Fully Supervised or Completed
Penalty
Summary
The facility failed to ensure medication administration was completed and supervised as ordered for one sampled resident who used a nebulized medication. The resident had an intact cognition and diagnoses of COPD, respiratory failure with hypoxia, and sleep apnea, and required moderate assistance with transfers, dressing, and hygiene. On one observation, the resident’s handheld nebulizer was found on the end table still connected to the machine with approximately half of the medication remaining in the cup, even though the MAR showed the treatment had been documented as completed hours earlier by an RN. The RN who observed the setup stated nursing should have followed up to ensure the medication was fully administered and that the nebulizer should have been disassembled and rinsed after use. A second observation the next morning again found the resident’s nebulizer assembled on the end table with about one-quarter of the medication still in the cup while the resident was asleep in bed. The LPN confirmed the nebulizer was still present with medication remaining and reviewed the MAR, which showed the last treatment had been given overnight. A self-administration assessment completed after the resident returned from the hospital stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. The consultant who completed the assessment acknowledged the resident’s record was not updated to reflect that she was no longer safe to self-administer nebulizer treatments, and the interim DON stated staff were expected to follow the facility’s nebulizer policy requiring staff to remain with the resident during the procedure and clean the nebulizer after completion.
Controlled Substance Diversion, Tampering, and Use of Discontinued Narcotics
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective safeguards and systems to prevent diversion and misuse of controlled substances, and to ensure discontinued controlled medications were promptly removed from use and accurately tracked. For multiple residents, discontinued narcotics and other controlled medications remained in the controlled substance boxes on medication carts for extended periods after the physician orders had been discontinued. Declining count sheets and return logs showed that large quantities of Lorazepam, Oxycodone, and Hydrocodone/Acetaminophen remained on the carts and were not returned to the pharmacy at the time of discontinuation, resulting in inaccurate narcotic counts. Surveyors identified specific instances of tampering and drug substitution in blister packs for several residents. For one resident, a discontinued Lorazepam 0.5 mg order left 90 tablets on the cart; the declining count sheet later showed 83 tablets remaining, but only 82 were actually returned to the pharmacy, with one tablet missing. For another resident with an Oxycodone 5 mg prescription, the declining count sheet and subsequent investigation revealed that three Oxycodone tablets had been removed and replaced with Metoprolol tablets, while the count sheet initially still reflected 90 tablets until the discrepancy was corrected to 87 Oxycodone tablets returned. For a resident prescribed Hydrocodone/Acetaminophen 10/325 mg, the blister pack was found to have one tablet replaced with a lower-dose Hydrocodone/Acetaminophen 5/325 mg, and only 42 of the original 60 tablets were returned. Additional residents’ Oxycodone blister packs were also found to be tampered with and to contain substituted medications. One resident with a short-term Oxycodone 5 mg order had a blister pack where six tablets did not match; investigation determined that three tablets had been replaced with Seroquel, two with Metoprolol, and one with Hydroxyzine, and only 12 Oxycodone tablets were ultimately returned. Another resident with a brief Oxycodone 5 mg order had one tablet replaced with Metoprolol, with eight Oxycodone tablets returned. Multiple nurses reported seeing narcotic blister packs on the carts that were taped on the back or had small breaks in the foil, and some packs contained pills that did not match the ordered narcotic. One nurse acknowledged that she sometimes taped blister packs back up when pills popped out, and several staff described discovering taped blister packs and pills that did not match the expected appearance of Oxycodone. The facility also failed to prevent administration of discontinued controlled medications. For one resident whose Lorazepam 0.5 mg order had been discontinued, the declining count sheet showed tablets being removed on several dates months later by two nurses, despite there being no active physician order and no corresponding entries on the Medication Administration Records. One of these nurses stated that her “system was not good,” that she administered medications based on what she believed residents received without checking the electronic MAR, and that whenever she removed Lorazepam for this resident, she administered it. For another resident whose Oxycodone 5 mg order had been discontinued, the declining count sheet showed doses removed on later dates by the same nurse, again without an active order and without MAR documentation. The DON and Regional Clinical Director repeatedly identified the core system failure as the lack of timely removal and return of discontinued controlled substances from the medication carts, which allowed misappropriation, tampering, and administration of medications without active physician orders. Throughout these events, documentation and verification processes for controlled substances were inconsistent or incomplete. Some pharmacy delivery receipts were unsigned, some declining count sheets lacked nurse signatures for doses removed, and notes on the count sheets documented that certain pills “did not match” the ordered medication. Staff interviews confirmed that taped blister packs and non-matching pills were observed during shift-change narcotic counts, and that concerns were not always immediately escalated. The cumulative findings showed that the facility’s systems for controlled substance storage, counting, discontinuation handling, and verification were ineffective, resulting in inaccurate narcotic counts, missing tablets, tampered blister packs, and removal and administration of controlled medications without active physician orders.
Failure to Properly Reconcile and Destroy Controlled Medications
Penalty
Summary
The facility failed to ensure the accurate and periodic reconciliation and proper disposal of controlled medications. During review of the controlled substance destruction records with the DON and Administrator, the double locked drawer used to store discontinued narcotics was observed to be full. The logbook showed that the last documented destruction of narcotics occurred on 11/06/25, and only one of six pages in the destruction log contained the required witness signature to validate the destruction process and ensure accountability. In a joint interview, the DON and Administrator stated that all discontinued narcotics were kept in a double locked drawer in the DON's office and acknowledged a significant accumulation of discontinued controlled substances. The DON reported that since her hire in December 2025, she had not conducted any narcotic destruction. They reviewed the narcotic destruction logbook and confirmed that the last documented destruction was on 11/06/25 and that only one of six pages contained the required witness signature. Facility policy titled Discarding and Destroying Medications stated that controlled substances were to be disposed of immediately, no longer than 3 days after discontinuation, and that disposal records were to include the signatures of two witnesses.
Medications Left Unattended at Bedside Without Observation
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe administration of medications in accordance with standards of nursing practice by leaving medications at the bedside and not directly observing residents taking them, despite no residents being assessed or authorized to self-administer medications. One resident was observed being handed a cup of medications, including Renvela and Tums for ESRD, by an RN who then left the room without observing ingestion; the resident placed the cup on the bed without taking the medications. Another resident was found with a cup of multiple medications left unattended on the bedside table with water; an LPN later entered, picked up the unattended cup, and then observed the resident take the medications. The facility’s Medication Storage policy requires that during a medication pass, medications must be under the direct observation of the person administering them or locked in a storage area or cart. Additional residents were also found with medications left at the bedside. One cognitively intact male resident receiving hospice care, with a history including dialysis and cancer, had a medication cup with three pills sitting on a cardboard box used as a bedside table; he stated that staff told him to take the medications “now,” but he did not always want to take them immediately. Another female resident with a history of hypertension, obesity, PTSD, urinary incontinence, weakness, and severe recurrent major depressive disorder with psychotic features had medication cups placed on her bedside table by an RN, who then left the room; the resident reported this occurred at other times and identified one cup as Tylenol for later and another cup with several pills for immediate use. The same RN acknowledged leaving medications at the bedside because it was the only way the resident would take them, stated she knew it was wrong, and confirmed awareness of the resident’s history of suicidal ideation. The facility’s self-administration policy requires IDT determination before self-administration and mandates reporting any unauthorized medications found at the bedside, and the DON confirmed that no residents were approved to self-administer medications.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Inaccurate MAR Documentation for Antihypertensive Medications with Parameter Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and systematically organized medical records for multiple residents, specifically related to the documentation of blood pressure (BP) and pulse parameters for antihypertensive medications. For three residents with significant cardiovascular and cognitive conditions, the Medication Administration Records (MARs) showed that BP medications were documented as administered even when recorded vital signs were outside the physician-ordered parameters to hold the medications. The facility’s Medication Administration policy required staff to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs were outside prescribed parameters, but the documentation did not accurately reflect whether medications were held or given. For one male resident with vascular dementia, congestive heart failure, hypertension, and a history of cerebral infarction, orders for Lisinopril and Carvedilol included parameters to hold the medications for systolic blood pressure (SBP) less than 110 and pulse less than 60. The April MAR showed that Carvedilol was documented as administered during an evening medication pass when the SBP was recorded at 109/57, which was below the ordered SBP parameter. The MAR listed the hold parameters, but there was no corresponding nursing progress note addressing the out-of-parameter SBP or clarifying whether the medication was actually given or held. For a second male resident with vascular dementia, cerebral infarction, and hypertensive heart disease, orders for Carvedilol, Hydralazine, and Losartan included parameters to hold the medications for SBP less than 100 or 110 (depending on the drug) and pulse less than 60. The March MAR showed that all three antihypertensive medications were documented as administered during a morning medication pass when the pulse was recorded at 54, below the ordered pulse parameter. The MAR reflected the hold parameters, but there were no nursing progress notes documenting the out-of-parameter pulse or any clinical decision-making related to the medications. For a female resident with vascular dementia, hypertension, and chest pain, orders for Lisinopril, Nifedipine ER, and Metoprolol Tartrate included parameters to hold the medications for BP less than 110/60 and pulse less than 60. The April MAR showed multiple instances where these medications were documented as administered despite recorded vital signs that were outside the ordered parameters, including pulses of 57, 59, and 58, and BPs with diastolic readings below 60. These discrepancies occurred on several different days and times prior to the resident’s discharge to the hospital for a UTI. There were no nursing progress notes documenting that BP or pulse readings were out of parameters on those dates. Surveyor observations of current medication passes by CMAs and LVNs showed that staff were obtaining BP and pulse, entering them into the electronic record (PCC), and checking parameters before selecting and administering antihypertensive medications, which was described as following professional guidelines. In interviews, CMAs and LVNs consistently stated that they always check BP and pulse, follow parameters, and hold medications when vital signs are outside ordered ranges, and one LVN acknowledged that she may have clicked the wrong box in the MAR, resulting in incorrect documentation even when a medication was held. The DON reported that there was no process in place to verify whether staff actually gave or held medications when vitals were outside parameters and confirmed that, although parameters were considered best practice and referenced in the medication policy, there was no separate policy requiring parameters. The policy review confirmed that staff were expected to obtain and record vital signs when applicable and to hold medications for vital signs outside prescribed parameters, and to correct discrepancies and report them to the nurse manager, which did not occur in the cited cases.
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