Failure to Maintain Accountability and Documentation for Controlled Substances
Penalty
Summary
The facility failed to maintain proper accountability and documentation for controlled substances, specifically fentanyl transdermal patches, for one resident. According to facility policy, all controlled substances must be accurately recorded on designated usage forms, with each dose administered and destroyed being witnessed and signed by two licensed staff members. However, review of the Controlled Drug Record sheets revealed multiple discrepancies, including missing documentation of quantities received, incomplete or missing nurse signatures for patch destruction, and instances where patches were signed out twice on the same day or with undated entries. In several cases, only one nurse signed for the destruction of used patches, contrary to policy requirements. Further review of the resident's medication administration records and related documentation showed inconsistent and incomplete entries regarding the placement and verification of fentanyl patches. There were instances where the same nurse signed as both the oncoming and off-going nurse, missing signatures, and lack of clear documentation of patch location or verification that the patch was in place. These documentation lapses made it difficult to accurately reconcile the number of patches dispensed, administered, and destroyed, resulting in a lack of clear accountability for the controlled substance. During an interview, the Director of Nursing was unable to provide a satisfactory explanation for the discrepancies in the documentation and could not account for the missing or improperly documented patches. The facility's failure to follow its own policies and federal regulations regarding controlled substance accountability led to this deficiency, as evidenced by the incomplete and inconsistent records for the resident receiving fentanyl patches.
Plan Of Correction
1. Resident #4 still currently resides in the facility. Her pain levels for the dates in question were reviewed and her pain levels were 0. She is comfortable and denies pain on her assessment. Her patch is in place and signed out appropriately. 2. Like residents are identified as those requiring controlled substance patches. The orders, and documentation of application and removal was reviewed for those like residents. 3. The revised and approved the Destruction of Narcotics policy and procedure. This policy identifies fully used narcotic vs. a narcotic that still has use. This policy further outlines destruction protocols for both. Licensed nurses were educated by the DON/designee by 4/25/2025 on appropriate process. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving controlled pain patches to ensure they are in place and documented appropriately. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.