The facility failed to maintain accurate controlled substance records when required shift-change narcotic counts were not completed and documentation for a resident’s oxycodone-acetaminophen was inaccurate. A resident with multiple chronic conditions had an order for scheduled oxycodone-acetaminophen, and a CMT removed and administered a dose without signing it out before administration. Later, the CMT documented the dose based on a prior quantity of six pills, resulting in a recorded balance of five, while only four pills were actually present in the card. The CMT reported arriving late and not completing the narcotic count, and an LPN acknowledged assuming, but not verifying, that counts had been done, contrary to facility policy requiring beginning- and end-of-shift counts and immediate documentation of narcotic removal.
The facility failed to accurately document, dispose of, and reconcile controlled substances for two residents. An unlocked narcotic lock box was found in a medication refrigerator with lorazepam bottles whose remaining amounts did not match the narcotic count log, and a morphine bottle in the medication cart also did not match the recorded count. The DON said staff should lock the box after counting and report discrepancies immediately, while an LPN said the count was off but had not yet informed the DON.
Staff failed to consistently document administration of controlled pain medications on both the MAR and the controlled substance records for three residents receiving opioid analgesics for chronic and PRN pain. Facility policy required special recordkeeping for DEA-controlled drugs and stated that current accountability records be maintained in the MAR or designated book. Record review showed numerous instances where hydrocodone-acetaminophen and oxycodone doses were signed out on the narcotic sheets without matching entries on the MAR, and in some cases, doses were documented on the MAR without corresponding narcotic sheet entries. Nursing staff and CMTs reported that they were expected to document on both records and that the two should match, while the administrator described the problem as a documentation issue.
The facility failed to administer time-sensitive medications as ordered and within policy-defined time frames for two residents. One resident on apixaban and flecainide had BID and Q12H doses that were either undocumented or given at widely varying times, without corresponding nursing notes explaining missed or late doses. Another resident with a sacral pressure ulcer and on anticoagulant therapy had metoprolol ordered for early morning administration but consistently received it several hours later, again without documentation of the variance. Staff interviews, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, showed inconsistent understanding of the liberalized medication pass and which medications were exempt, contributing to inconsistent adherence to ordered administration times.
A cognitively intact resident with multiple chronic conditions had a full set of scheduled morning oral medications prepared and signed out on the MAR by a CMT, who then asked an LPN to deliver them. The LPN placed the medications at the bedside at the resident’s request for milk, left to obtain the milk, returned with it, and then left the room without observing the medications being taken, despite facility policy prohibiting leaving medications at bedside without a physician’s order. Later, the resident reported the medications were missing, and a CNA notified the LPN; the resident subsequently found the pills in the bed. In interviews, the resident reported that staff do not stay to observe medication administration, and the CMT, LPN, ADON, and Administrator all confirmed that there was no order to leave medications at bedside and that medications should not have been left unattended, while the CMT had already documented administration on the MAR.
Staff failed to ensure accurate administration and documentation of an antibiotic and steroid regimen for a resident with COPD and pneumonia. The physician ordered cefdinir for a defined seven-day course and a tapering prednisone schedule, but the MAR showed cefdinir documented for ten days while a medication card still contained unused doses, and progress notes indicated the drug was unavailable on some of the days it was charted as given. Prednisone doses for two ordered periods were not documented as administered, and an unopened prednisone card was found despite active orders. Multiple CMTs, LPNs, the DON, and the Medical Director acknowledged that medications should be given and documented as ordered, that blanks on the MAR indicate doses were not given, and that unavailability should be recorded, yet there were unexplained discrepancies between orders, MAR entries, and actual medication availability.
Surveyors found that the facility failed to accurately reconcile and document the administration and destruction of Schedule II, IV, and V controlled substances for several residents. Policies required that controlled substances be fully accounted for, with doses on usage forms matching the MAR and controlled drug records, and that staff sign both the MAR and narcotic book after administration. Instead, surveyors identified multiple cases where the DON and ADON documented destruction of narcotics on Controlled Drug Receipt/Record/Disposition forms, yet subsequent entries on the same forms showed additional removals of tablets without corresponding MAR entries and, in some cases, without active orders. Typed destruction logs often listed destruction dates and quantities that did not match the handwritten disposition forms. Nursing staff reported that when narcotic orders are changed or discontinued, nurses pull the medication and log and give them to the DON or ADON for destruction, and that floor staff do not destroy narcotics, but acknowledged that documentation errors occurred during this process.
Nursing staff failed to maintain an effective reconciliation system for controlled substances when two nurse medication carts, containing all PRN controlled meds, lacked signature sheets for beginning and end of shift narcotic counts. Although nurses reported that off-going and oncoming staff verbally counted the quantity of each controlled medication and total packages on the Skilled 1 and Skilled 2 carts, they did not sign to confirm these counts and had never done so during their months of employment. Review of the controlled medication books confirmed the absence of signature sheets, and both the DON and Administrator stated that nurses were expected to sign each shift to verify completion and accuracy of narcotic counts, but the DON had not been auditing to ensure this occurred.
A resident with opioid dependence and other medical conditions received Oxycodone for pain management. The facility lost one narcotic count sheet for a card of 30 Oxycodone tablets, resulting in no reconciliation for those doses. While the MAR showed administration of the medication, the required controlled substance documentation was incomplete, and staff interviews confirmed the missing record.
The facility did not consistently ensure that two nurses verified and signed the controlled substance inventory tracker sheets at shift changes, resulting in incomplete and inaccurate documentation for one floor. Despite policies requiring dual signatures and thorough recordkeeping, multiple instances were found where only one nurse signed or signatures were missing entirely, and some medication additions lacked proper documentation. This failure prevented accurate reconciliation of controlled substances as required by regulations.
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