Failure to Account for and Secure Controlled Medications in Emergency Kit
Penalty
Summary
The facility failed to maintain a system for accounting for controlled medications, specifically regarding the receipt and disposition of narcotics in the emergency kit. On multiple occasions, the door to the Administrative Nurse's office, where the emergency kit was stored, was found unlocked and unattended. The emergency kit itself was received with one of its drawers unlocked, containing Schedule 2 controlled substances such as fentanyl patches, morphine, and tramadol, among others. The kit did not include an inventory list of the narcotic medications, and staff were unable to access two of the three drawers. The facility did not have a policy related to the storage of narcotic medications and did not require a receipt upon delivery of the emergency kit. The pharmacy was notified of the issue with the emergency kit, but did not promptly resolve the problem. When a replacement kit was brought, it also lacked an inventory and contact information for unlocking, leading the facility to refuse it and return the damaged kit. The consultant pharmacist confirmed that the emergency kit should not have been accepted if it was damaged or unlocked, and that proper documentation and inventory should have been provided. The lack of a detailed system for tracking controlled substances and the absence of a storage policy contributed to the facility's inability to accurately reconcile and safeguard narcotic medications.