Inaccurate Accounting of Narcotic Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of narcotic medications for a resident and accurate controlled medication records on a medication cart. Specifically, a review of a resident's clinical record revealed that doses of Oxycodone, a narcotic opioid pain medication, were signed out by nursing staff but not recorded on the resident's Medication Administration Record on two separate occasions. This discrepancy indicates a failure in the administration and documentation process for controlled substances. Additionally, the facility's "Control Substance Shift to Shift Count Sheet" for a medication cart showed multiple instances where nurses failed to sign off on the narcotic count, indicating that the count was completed and correct. These omissions occurred over several days, further demonstrating inconsistencies in the facility's procedures for maintaining accurate controlled drug records. The Director of Nursing confirmed these inconsistencies during an interview, acknowledging the facility's failure to consistently implement procedures for promoting accurate controlled drug records.
Plan Of Correction
- C2-assessed with no negative outcomes. - Facility Narcotic Records assessed for any other issues with Narcotic count on 1/7/25 with no ill regularities noted. - Employee responsible for inadvertent signing re-educated on 1/7/25. Mandatory Directed Inservice training will be completed with all licensed staff. This includes but not limited to policy entitled, "Administering Medications". This also includes but not limited to proper shift to shift narcotic counts, documentation requirements and procedures for addressing discrepancies. - A root cause analysis will be conducted with the assistance from the QAPI committee and governing body. - The DON or designee will conduct weekly audits x 4, then monthly x 2. - Audits will be presented at the monthly QAPI committee for ongoing oversight.