Failure to Secure Medication Cart and Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain a secure medication cart and accurate controlled medication records for a resident who was admitted and later discharged. During a routine narcotic reconciliation on one of the facility's halls, it was discovered that a narcotic count sheet for oxycodone HCL was missing from the medication cart. The incident was identified during a shift change narcotic count conducted by two nurses, one of whom admitted to leaving the narcotic keys on top of the cart during her breaks and could not recall the name or description of the nurse she shared the cart with. The missing count sheet could not be located despite an audit of all medication carts. Interviews with staff revealed that the facility's expectation was for narcotic drawers and medication carts to remain locked at all times when not in use, and for nurses to keep the medication cart keys on their person. The process for receiving and storing narcotics was described, including verification and secure storage, but the missing count sheet indicated a lapse in these procedures. The pharmacy consultant confirmed that she was notified of the incident and had not observed similar issues before or after this event. The facility's draft plan of correction was not substantiated due to a lack of defined auditing and monitoring related to narcotic count sheets and key security.