Controlled Substance Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled substances, specifically Oxycodone, for a resident. The pharmacy delivered 56 tablets of Oxycodone 10 mg for a resident, but the Individual Resident's Controlled Substance Record inaccurately documented that only 46 tablets were received. Furthermore, the record showed 41 tablets available, while the actual count in the blister packs was 50 tablets. This discrepancy was not identified by the nursing staff during the required shift change reconciliation process. The resident involved was admitted with conditions including pain, osteomyelitis, and a stage 4 pressure ulcer, and was on a scheduled pain medication regimen. Despite the facility's policy requiring narcotics to be counted and reconciled at each shift change, the discrepancy in the Oxycodone count was overlooked by the nurses responsible for medication administration and reconciliation. Interviews with the nursing staff revealed a lack of awareness and oversight in accurately documenting and reconciling the controlled substance records, which was acknowledged by the Assistant Director of Nursing Services and the Director of Nursing Services.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 755 – Pharmacy Services The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: a) There was no psychological harm or complaint of pain for Resident #162 as a result of this deficient practice. b) For Resident #162, the narcotic [MEDICATION NAME] 10mg was reconciled to reflect the accurate number of tablets received as 56 tablets on 12/18/2024. c) The Licensed Practical Nurse who inaccurately documented the number of [MEDICATION NAME] received from the pharmacy for Resident #162 received an educational counseling dated 12/18/2024. d) The Licensed Practical Nurses responsible for reconciling the narcotic count of [MEDICATION NAME] for Resident #162 at beginning and ending of shifts and failed to observe the inaccurate count, received an educational counseling on 12/18/2024. e) The Licensed Practical Nurse who failed to immediately reconcile the narcotic count of [MEDICATION NAME] for Resident #162 after medication administration received an educational counseling on 12/18/2024. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents on controlled medication have the potential to be affected by the deficient practice. Upon identification of the inaccurate narcotic count for the medication [MEDICATION NAME] for Resident #162 on 12/18/2024, the Nurse Managers conducted an immediate audit of all narcotics on all units to ensure there were no further discrepancies in the number of tablets received and documented. There were no negative findings. The Nurse Managers also conducted an audit on 12/18/2024, reviewing the narcotic book to ensure that licensed nurses were immediately documenting and reconciling the narcotic count after medication administration. There were no negative findings. C) Systemic Changes to ensure the deficient practice will not recur: The facility policy and procedure titled “Controlled Substance/ Narcotic Management” was reviewed and found to be in compliance. All Licensed Nurses will be re-educated on the importance of ensuring an accurate narcotic count as well as reconciling the narcotic count immediately after the medication is administered. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: The Managers and RN Supervisors will be responsible for auditing the narcotic books on a daily basis x 3 weeks then weekly x 3 months to ensure accuracy of narcotic count and timely reconciliation after medication administration. Any negative findings will be immediately corrected and reported to the Assistant Director of Nursing for follow up and report to the QAPI committee. The Assistant Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025