Failure to Investigate Medication Error and Improper Controlled Substance Disposal
Penalty
Summary
The facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications for a resident with multiple complex diagnoses, including acute respiratory failure, subdural and intracerebral hemorrhages, and tracheostomy status. The resident was prescribed Methadone, but due to incorrect transcription of the order and confusion regarding the supply from the pharmacy, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml). The error was not discovered until the following day during the scheduled morning dose, and documentation on the medication administration record did not match the narcotic sheet, which showed four bottles signed out. There was no documentation of the wasted Methadone. Further investigation revealed that the narcotic count was not completed correctly during shift changes, and the narcotic log did not include the required documentation of a second nurse witnessing the medication waste. The nurse involved confirmed she flushed the remaining Methadone down the toilet, which was against facility policy and Environmental Protection Agency regulations. The facility's investigation did not identify the lack of a second nurse as a witness to the medication waste, and the nurse could not recall who, if anyone, witnessed the destruction of the medication.