Inappropriate Borrowing of Controlled Substances Among Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by the inappropriate borrowing of controlled substances among residents. Specifically, the facility used one resident's oxycodone to administer to three other residents when their medication was unavailable. This practice was contrary to the facility's policy, which required controlled drugs to be fully labeled and stored securely, and did not have a documented policy on borrowing medications. The deficiency involved four residents, each with physician orders for oxycodone to manage pain. The facility's records showed that one resident's oxycodone was borrowed multiple times for other residents over a period of several weeks. Interviews with nursing staff revealed that borrowing medications was considered a facility policy, although it was not documented, and was used as a stopgap measure when residents were readmitted from the hospital without prescriptions or when there were delays in medication delivery. The Director of Nursing and the Pharmacist confirmed that borrowing controlled substances was not appropriate and could lead to issues such as diversion and billing problems. The facility had an emergency medication supply system, but it was not fully stocked with all necessary narcotic pain medications, leading to reliance on borrowing. The Medical Director stated that electronic prescriptions could be sent for immediate fills, but this was not utilized, resulting in the inappropriate borrowing of medications.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F755- Pharmacy Services/Procedures/Pharmacist/Records: Crouse Community Center will ensure medications are available for residents when needed. Corrective action: Resident # 1, #208, #209 had new prescriptions obtained with their own sufficient, designated supply of medications received. Resident # 88 has a sufficient supply of medications. Other residents: All other residents with orders for controlled substances were reviewed to ensure sufficient supply of medication. Systemic Changes: Crouse Community Center will ensure that all residents with controlled substances will have a sufficient supply of medications. Licensed staff was educated on the modifications made to the facility Stat Safe. Pharmacy was consulted, and the facility Stat Safe medication emergency supply system was updated with additional emergency controlled substances added. Monitoring: Audits will be conducted weekly by the Director of Nursing to ensure sufficient supply of controlled substances. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing