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Based on document review and interview, the facility failed to restrict an unauthorized employee from having access to controlled substances in the automated dispensing cabinet, failed to restrict an unauthorized employee from administering controlled substances (A7, Registered Nurse [RN]) and failed to have a system in place to prevent access to controlled substances for individuals with restrictions.

The cumulative effects of this systemic problem prevented the facility from providing medication administration by nursing in a safe manner.

Based on document review and interview, the facility failed to restrict an unauthorized employee from having access to controlled substances in the automated dispensing cabinet, failed to restrict an unauthorized employee from administering controlled substances (A7, Registered Nurse [RN]) and failed to have a system in place to prevent access to controlled substances for individuals with restrictions.


Findings include:

1. Review of policy/procedure titled, "MM 07-001 Controlled Substances," PolicyNo.: 17743065, last approved 03/2025; indicated under: Part III - Storage. Under Restricted Access: In the patient care area, access to controlled substances in the automated dispensing cabinets (ADC) is controlled by pharmacy. Under: Part V - Administration: Controlled substances are administered by authorized personnel to registered patients of the facility pursuant to a valid practitioner's order.

2. Review of State Professionals Recovery Program (IPRP) RMA Nurses indicated on page 6, A7 does not have access to controlled substances through their employer. Under I. Narcotic restriction: A7 understands they have a narcotic restriction for a minimum of 6 months. Further, A7 understands the narcotics restriction requirement must be met at the same employer for the entirety of the narcotic restriction. V. Length of RMA: This RMA will remain in effect for a minimum of 5 years, signed 09/11/2023. Addendum to the RMA: C. Change in RMA with supporting rationale: removal of narcotics restriction. Participant provided two rationales for support, signed 03/20/2025.

3. MR review for P2 indicated the following:
Review of electronic medication administration record (e-MAR) for 02/05/25 - 03/18/25, indicated P2 received a controlled substance medication, Lorazepam, administered by A7 on 02/28/25 at 2204 hours.

4. MR review for P5 indicated the following:
Review of e-MAR for 02/05/25 - 03/18/25, indicated P5 received a controlled substance medication, Lorazepam, Benadryl and Haldol mixture, administered by A7 on 02/25/25 at 2318 hours and on 03/04/25 at 2238 hours.

5. MR review for P7 indicated the following:
Review of e-MAR for 02/05/25 - 03/18/25, indicated P7 received a controlled substance medication, Lorazepam, administered by A7 on 02/28/25 at 2207 hours.

6. Interview with A2 (Director of Nursing [DON]) on 03/27/25 at approximately 11:15 a.m., confirmed A7's name on the e-MAR indicated A7 administered Lorazepam to P2 and P7, and Lorazepam, Benadryl, and Haldol mixture to P5.

7. Interview with A2 on 03/27/25 at approximately 4:25 p.m., indicated they were aware of A7's controlled substance agreement, and A2 confirmed A7 has e-signed they administered controlled substances to 3 out of 10 patients reviewed. A2 confirmed A7 is not supposed to do that. A2 indicated they and A7 must follow the rules from State Nursing Assistance Program (SNAP) and Recovery Monitoring Agreement (RMA).

8. Interview with A15 (RN) on 03/27/25 at approximately 4:35 p.m., confirmed whatever staff is logged into the system will be the name on the e-MAR for that patient.

9. The facility failed to have system in place to prevent access to controlled substances for individuals with restrictions.