Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to implement procedures to prevent the misappropriation of resident property, specifically narcotic medications, for one resident. Resident 16, who was admitted with multiple rib fractures, a periprosthetic fracture, and dysphagia, had a physician order for Tramadol 50mg for chronic pain. On January 27, 2025, the pharmacy delivered 30 tablets of Tramadol 50mg to the facility for Resident 16, but the medication card and sign-out sheet went missing the same day. An investigation revealed that Employee 8, an LPN, received and signed for the delivery and placed the medications in the medication room, informing Employee 11, another LPN, of their location. However, the medications were left unattended, and Employee 11 did not recall handling the Tramadol. Video footage showed Employee 11 leaving the narcotic drawer open and unsecured while stepping away from the medication cart. Despite the controlled substance shift-to-shift count sheets confirming medications were accounted for, discrepancies were noted after the pharmacy alerted the facility of the missing medications. The facility's investigation did not include written witness statements from Employees 8 or 11, nor from other nursing staff assigned to the medication cart during the relevant period. Although Resident 16 did not miss any doses due to an existing supply, the misappropriation of medication was confirmed, and the investigation failed to identify the perpetrator responsible for the missing controlled substances.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the Tramadol was not found and the perpetrator not identified. The delivery of all narcotic medications will be checked and co-signed by the RN Supervisor/licensed designee and the LPN Charge Nurse assigned to the resident(s). If the LPN Charge Nurse is unavailable, another LPN can co-sign the narcotics. A copy of the narcotic(s) sheet, from the pharmacy will be copied and placed in a binder for the Director of Nursing. The RN Supervisor/licensed designee and LPN assigned to the resident(s) will place the narcotic in the appropriate medication cart(s) and the narcotic sheet(s) in the narcotic binder(s) located on the medication carts. The RN Supervisor and LPN co-sign placement of the narcotic in the locked box in the medication cart and on the Narcotic Medication Sheet. Educate employees on diversion awareness and recognizing indicators of impairment and diversion activity. The education program will be discipline specific and done on new employee orientation and annual mandatory education. Training will be conducted in a classroom setting and online learning modules. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months. The weekly Risk Management Committee will include narcotic oversight and will be responsible for developing and maintaining policies to prevent and respond to potential drug diversion while ensuring system standardization in practice, detection, security, and investigation related to controlled substances. The pharmacy will audit the Omnicell, secure dispensing cabinet and a camera above the Omnicell will be installed to identify staff members, verify opioid counting, identify a theft, and establish a time frame for investigation. The pharmacy will utilize monthly user reports to provide a list of users, wasting, overrides, and the number of controlled substances pulled. The pharmacy will notify the Director of Nursing and the Administrator of any trends or errors and report findings monthly in QAPI x 12 months. A list of all residents on narcotics will be compiled and a random audit of five residents per week will be audited for individual narcotic log maintenance and accurate narcotic counts. Weekly, a random medication cart will be inspected checking each drawer and compartment to ensure all medications are properly stored, labeled, within their expiration dates, and the cart is clean, functional, and secure, including the locking mechanism. The results of the random narcotic count audits, medication cart inspections, and narcotic sheets will be a Performance Improvement Project for Nursing and presented at QAPI monthly x 12 months.