Failure to Report Missing Narcotic
Penalty
Summary
The facility failed to report a discrepancy involving 4 milliliters of morphine missing from a resident's supply. The resident, who was cognitively intact and had multiple medical diagnoses including atrial fibrillation, coronary artery disease, diabetes mellitus, and emphysema, was prescribed morphine sulfate for pain management. According to the Individual Narcotic Record, the resident should have had 4 milliliters remaining in the bottle, but only 0.25 milliliters could be drawn. Staff involved in the medication administration and narcotic count did not immediately report the missing narcotic to the Director of Nursing (DON) as required. Instead, staff assumed the discrepancy was due to spillage or manufacturer variance and signed off on the count as corrected, discarding the bottle without further investigation or notification. The DON was not informed of the missing morphine until the following day, after which she conducted an internal review. Staff interviews revealed that narcotic counts were not consistently performed at shift changes, and staff were unaware of the requirement to report missing narcotics immediately. The DON ultimately determined that the discrepancy could be explained by possible spillage and manufacturer variance, and did not report the incident to the State Agency, as she did not suspect drug diversion. The failure to promptly report the missing controlled substance and the results of the internal investigation to the appropriate authorities constituted the deficiency.