Incomplete DEA 222 Forms for Controlled Medications
Penalty
Summary
The facility failed to ensure that all DEA 222 forms were completed with sufficient detail for accurate accountability and reconciliation of controlled medications. This deficiency was identified in six out of six DEA 222 forms reviewed in the backup controlled medication storage area. The forms, dated between August and December, were missing the number of controlled medications received and the date they were received, as required in Part 5 of the form. The Director of Nursing (DON) was unaware of the requirement to fill in Part 5, as she had not read the instructions on the form and was following previous instructions given to her. Interviews with the facility's pharmacy provider and the Medical Director (MD) revealed that the process required the purchaser, or nursing home, to complete Part 5 of the DEA 222 forms. The Pharmacist and the Chief Executive Officer/Consultant Pharmacist (CEO/CP) confirmed that the nursing department was responsible for documenting the quantity and date of receipt of controlled medications. The MD stated that he only signed the forms and was not involved in the receipt of medications. The CEO/CP noted that the Consultant Pharmacist, who checked the forms quarterly, had not verified the completion of Part 5, which was a mandatory requirement according to Board of Pharmacy regulations.
Plan Of Correction
1. No resident had a negative outcome due to the deficient practice of incomplete 222 forms section 5. On 12/20/2024, US FOIA (b)(6) received 1:1 education by the Regional Director of Nursing on the importance of completing section 5 of the 222 form and attaching the packing slip when medication is received. 2. All residents on narcotic medication have the potential to be affected by the deficient practice. Section 5 of the 222 forms were reviewed to ensure completion. 3. On 12/20/2024, the Regional Director of Nursing educated the US FOIA (b)(6) on the importance of completing section 5 of the 222 forms. In addition, a new process was implemented where the pharmacy consultant will audit 222 forms on a monthly basis. 4. The Director of Nursing will audit 222 forms weekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reported to the QAPI Committee monthly for 3 months.