Narcotic Management Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to provide adequate pharmaceutical services and maintain proper drug records, resulting in unaccounted narcotic medications across four units. On the River View unit, 93 narcotic medications were missing, and the keypad to the medication room was malfunctioning, allowing access via employee swipe badges. Additionally, the lock on the narcotic cupboard was broken, and the issue was not addressed until after the medications went missing. Observations revealed that narcotic reconciliation books and keys were left unattended in medication rooms on both the River View and Sky View units. Licensed Practical Nurse #1 was observed conducting a narcotic reconciliation alone on the City View unit, contrary to the facility's policy requiring two nurses to perform the count together. The facility's records showed numerous shifts across all units where narcotic reconciliation was not documented as completed by both the outgoing and incoming nurses. Interviews with staff, including the Director of Nursing and a consultant pharmacist, confirmed that narcotics should be reconciled every shift to ensure accurate counts and prevent diversion. The facility's failure to adhere to its Controlled Substance Management policy, which mandates proper storage and reconciliation of narcotics, contributed to the discrepancies in narcotic counts. The lack of consistent documentation and adherence to procedures for narcotic reconciliation and key management posed a risk of medication diversion and compromised the facility's ability to account for controlled substances accurately.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 LPN #1 and LPN #3 were placed on administrative leave, then thereafter were counseled regarding the Controlled Substance Management Policy. LPN #3’s counseling emphasized that the off-going shift nurse must remain on the unit with the keys until the on-coming nurse arrives and a narcotic count is performed with both nurses and documented in the Narcotic Book(s). It was also emphasized that keys are to be kept with the nurse on shift at all times and cannot be left unattended in the medication room or anywhere else at any time. LPN #2 was counseled to report the off-going nurse leaving before counting off narcotics to supervision right away. The provider assessed residents whose narcotics were missing to ensure there are no adverse effects as a result of the missing medication. Education was provided on the process of handing off keys and signing of narcotics in relation to not leaving the unit prior to having a relief, ensuring all signatures are in place and match the narcotic count. No residents were affected by the deficient practice. All narcotics on the units were audited and accounted for; no other issues were identified. The Controlled Substance Management Policy and Medication Administration policy were reviewed by the DON; no revisions required. All licensed nurses will be educated on the Controlled Substance Management Policy and Medication Administration policy with emphasis placed on the shift-to-shift count process with key hand off and expectation that the off-going nurse is to remain on the unit with keys on their person until the oncoming nurse arrives and count is performed – keys are not to be left unattended at any time. Medication competency with licensed nursing staff will be completed to ensure compliance. Unit Managers/Designee will conduct audits on the Narcotic reconciliation book on their assigned unit weekly for 4 weeks, then bi-weekly for 2 months. The audit will ensure that medication reconciliation records have two nurse signatures for each shift-to-shift count with no missing entries. Unit Managers/Designee will monitor 1 shift count on each shift twice weekly for 2 weeks, then weekly for 4 weeks to ensure the off-going nurse and oncoming nurse are counting narcotics appropriately, handing off keys appropriately, and documenting. Audit findings will be reported to the QAPI committee for review monthly. Responsible Person: DON