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.
A resident admitted for respite care with an anxiety disorder had PRN Lorazepam supplied from home, and staff documented an initial count of more than the labeled quantity. Discrepancies arose between the MAR and the narcotic sign-out sheet, and staff interviews showed that controlled medications from home were not consistently counted at each shift change once the resident was hospitalized, resulting in 31 unaccounted Lorazepam tablets. In a separate issue, narcotic records for a medication cart showed mismatched counts between the number of controlled medication cards/liquids and the Inventory Sheet, with missing times, signatures, strengths, and incorrect totals after a pharmacy delivery of additional controlled medications, indicating inaccurate and incomplete narcotic documentation.
A resident with diabetes and neuropathy, prescribed daily Lyrica 25 mg for neuropathic pain, missed four consecutive doses when the facility failed to maintain an effective system for refilling and obtaining the controlled medication. MAR entries and progress notes showed the drug was repeatedly documented as "on order" while multiple nurses on different shifts reported the medication was unavailable, attempted to reorder it, and notified supervisory staff. The Unit Manager described reliance on nurses to call the pharmacy for refills and noted that agency nurses often did not understand the process, while the pharmacy required a current prescription and had no record of an early refill request. The NP reported he responds to refill emails multiple times daily, and the Pharmacy Director stated that if procedures had been followed, the resident should not have run out of Lyrica; leadership later acknowledged that the resident’s medication had run out.
The facility failed to accurately document and reconcile controlled medications for multiple residents, including those receiving hydrocodone-acetaminophen, oxycodone, and Oxycontin for pain. For one resident with metastatic cancer and severe pain, controlled drug records showed more doses removed from locked storage than were documented as administered on the MAR, and several nurses admitted to forgetting MAR documentation, misdating removals, or signing out doses without times to correct off-counts. On one unit, the controlled substance count sheets over several days lacked required dual signatures, omitted counts of cards and sheets, and contained undocumented additions and subtractions of medication cards, with some shifts showing no recorded reconciliation at all. For another resident on chronic Oxycontin, the pharmacy’s dispense and return records did not match the facility’s controlled drug records, and neither the pharmacist nor the corporate nurse consultant could reconcile the discrepancies. A third resident on scheduled Oxycontin and PRN oxycodone had MAR entries indicating doses were given without corresponding removals on the controlled drug record, and nurses later reported holding doses without correcting the MAR, giving PRN oxycodone instead of scheduled Oxycontin without clear documentation, or being unable to explain mismatched records.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO BID, but eight consecutive doses were not administered over several days because the medication was repeatedly unavailable. Multiple nurses documented the drug as unavailable, did not consistently check the automated dispensing machine, and often failed to contact the pharmacy or request use of the backup system, while one nurse learned of a discrepancy between the pharmacy’s once-daily entry and the facility’s BID order but did not escalate it to the DON or physician. The DON stated she expected medications to be administered as ordered and that staff should use the automated dispensing machine and backup pharmacy when medications are not on hand, and the Pharmacy Manager reported that the pharmacy had entered the order incorrectly and that, if notified, the medication would have been supplied through backup processes, noting the potential risk of infection worsening from the missed doses.
A resident with COPD, depression, and bipolar disorder did not receive multiple doses of newly ordered Divalproex, Olanzapine, and Trelegy Ellipta after admission because the medications were never obtained from the pharmacy. Over several days, nurses documented on the MAR that these medications were not administered and repeatedly noted they were "on order," with one nurse acknowledging she did not check the Pyxis and did not contact the family for a home supply. Staff believed administrative nurses had ordered the medications and that orders would transmit electronically to the new pharmacy as with the prior system, but the pharmacy later confirmed it did not receive faxed orders for these drugs until several days after they were written, during which time the resident went without the prescribed anticonvulsant, antipsychotic, and triple-therapy bronchodilator.
Surveyors found systemic failures in controlled substance management, including a case where oxycodone doses were signed out for a resident after the resident had been sent to the hospital, with no corresponding MAR documentation and an unreadable second signature. In addition, two residents did not have their prescribed oxycodone available, leading multiple nurses and a Unit Manager to repeatedly borrow oxycodone from other residents’ supplies over several days, despite the absence of a borrowing policy and without consistent DON notification or documentation of replacement. Monthly pharmacy audits over several months documented missing nurse signatures on shift‑change counts, discrepancies between controlled substance records and MARs for opioids and lorazepam, incorrect card counts, early PRN administrations, and wasting without a second nurse witness, while facility leadership reported being unaware of these specific controlled substance issues and did not fully reconcile or act on the audit findings.
A resident had a PRN oxycodone 5 mg order, with documentation showing several doses administered and seven tablets remaining at discharge. An RN completed a controlled substance return form and sealed the remaining oxycodone in a return bag without having a second nurse verify the medication, while another nurse signed the form without seeing or counting the drugs. A third nurse later released the sealed bag to the pharmacy driver after only confirming the bag’s serial number matched the pick-up ticket, without checking the contents. The pharmacy documented that no oxycodone was in the bag upon receipt and reported the discrepancy to facility staff, and the missing tablets were never located.
The facility failed to maintain proper accountability and documentation for multiple residents’ controlled medications, including lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol. Pharmacy records showed that controlled drugs were delivered, but declining count sheets were missing, narcotic book entries were absent, and delivery receipts were often signed by only one nurse or not signed at all. For one resident, lorazepam tablets were delivered for a time-limited PRN order with no evidence of administration, no inventory log, and no return to the pharmacy after discontinuation. Interviews with the DON, a unit manager, the consultant pharmacist, the pharmacy nurse consultant, and the pharmacy director revealed that no one was consistently auditing controlled medications, second-nurse verification at receipt was not reliably performed, and discontinued controlled drugs were not systematically removed from carts and returned, leading to unaccounted-for controlled substances.
The facility failed to maintain effective systems for shift-change narcotic reconciliation and secure storage of discontinued controlled substances, resulting in 80 missing oxycodone-containing tablets for two residents. One resident with PRN oxycodone/acetaminophen had a full card of tablets present one afternoon, but the next morning the oncoming MA and off-going nurse skipped the required physical narcotic count on one cart, relying on verbal confirmation instead; later that morning, when the resident requested pain medication, the MA found that the oxycodone/acetaminophen blister pack was missing. For a second, recently deceased resident with PRN oxycodone via gastric tube, a nurse removed the narcotics from the locked drawer and placed them in a pharmacy return bag left in the medication room; the next day the MA carried this bag to a nurse manager, who then stored it in an unlocked cabinet at the nurse’s station. When two nurses later attempted to count and scan the medications for return, they discovered that the oxycodone tablets for this resident were missing, confirming that discontinued narcotics had not been kept under the required double-lock system.
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