Narcotic Inventory Discrepancy for a Resident
Penalty
Summary
The facility failed to maintain an accurate inventory of narcotics for a resident, identified as Resident 35, which led to a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). Specifically, two tablets of Percocet were removed from the medication card on two separate occasions, but there was no documentation in the MAR to confirm that these medications were administered to the resident. This discrepancy was confirmed during a review of the records by the Director of Nursing (DON), who acknowledged that the CDR documentation did not match the MAR documentation, and there was no way to verify if the narcotics were given to the resident. Resident 35, who was admitted to the facility in 2019, had a principal diagnosis of acute respiratory failure. The physician's orders indicated that Percocet was to be administered as needed for pain. However, the facility's failure to document the administration of the narcotics in the MAR as per their policy and procedure titled 'Administering Pain Medications' resulted in an increased potential for drug diversion and inaccurate monitoring of the resident's medication regimen.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 35 was assessed and no concerns were noted. The medical director was notified of the alleged deficient practice. Pharmacy Consultant and the Nurse Practitioner reviewed the current medications order of Resident 35 on 3/24/2025. Licensed Nurses (LNs) who failed to ensure accurate inventory/documentation of narcotic medication received a 1:1 in-service education on 03/24/2025 by the Director of Nursing Services (DNS) related to appropriate procedures on narcotic medication administration and documentation. The DNS provided in-service training to all LNs on 03/24/2025 on the correct procedures on administering and signing off narcotic medications in order to maintain an accurate reconciliation. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the alleged deficient practice as failure to keep accurate inventory of narcotics can lead to potential drug diversion resulting in improper drug usage and harm. Resident 35 narcotics was audited on 3/13/2025 and all residents currently receiving a narcotic pain medication were audited by the DNS/Designee on 03/14/2025 to ensure accurate inventory of narcotics. Effectiveness, location and intensity were documented after the PRN narcotic pain medication to evaluate their pain level. Upon identification of the alleged deficient practice, a new pain assessment was conducted on residents noted to have been given a PRN narcotic pain medications for the last 7 days to evaluate their pain level and ensure accurate inventory of narcotic had been documented in eMAR. No similar issue identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure accurate inventory of narcotics are entered in e MAR to prevent the potential for diversion. The DNS provided in-service training to all LNs on 03/24/2025 on the correct procedures on administering and signing off narcotic medications in order to maintain an accurate reconciliation. LNs in their respective shifts will ensure that accurate inventory of narcotics are entered in e MAR to prevent the potential for diversion. The DNS/Designee will conduct medication pass observations daily x 1 week and weekly x 3 months to ensure licensed nurses are following the protocol on narcotic medication administration and documentation. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will monitor for compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025