Failure to Accurately Reconcile and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications for a resident who was prescribed liquid morphine sulfate for pain management. The resident, who was cognitively intact and had multiple medical diagnoses including atrial fibrillation, coronary artery disease, diabetes mellitus, and emphysema, received morphine as ordered. According to the Individual Narcotic Record (INR), there should have been 4 milliliters remaining in the bottle on a specific date, but only 0.25 milliliters could be drawn from the bottle. Staff interviews revealed that a proper shift change narcotic count was not completed between two nurses, and the discrepancy in the morphine count was not immediately reported to the Director of Nursing (DON) as required. Staff involved in the incident provided conflicting accounts regarding the missing morphine. One nurse stated she assumed the missing medication was due to spillage over time and signed off on the INR as corrected without reporting the discrepancy. Another nurse admitted to not completing the required narcotic count at shift change and later felt pressured by the DON to claim she had spilled the morphine, despite not recalling such an event to the extent of the missing amount. The DON, upon being informed of the discrepancy, initiated an investigation and attempted to account for the missing morphine through staff interviews and reference to manufacturer’s instructions regarding possible volume variance in the bottle. Despite these efforts, the missing morphine was not discovered during numerous prior shift change narcotic counts, and the facility did not report the discrepancy to the State Agency. The documentation and reconciliation process for controlled substances was not followed as required, and staff failed to ensure that all doses were properly accounted for and discrepancies promptly reported and investigated.