Failure to Maintain Accurate Controlled Substance Records Resulting in Drug Diversion
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and ensure that drug records were in order. Specifically, the facility was unable to account for 55 tablets of Hydrocodone (Norco) prescribed to a male resident with Alzheimer's disease, chronic pain, and type II diabetes. The medication was delivered and signed for, but the corresponding medication card and count sheet could not be located, and the facility was unable to determine the disposition of the controlled substance. During the period in question, the resident was transferred from one unit to another during a shift change. Staff interviews revealed that narcotic counts were not consistently performed during the transfer, and there was no clear documentation of the medication card's receipt or reconciliation at the time of transfer. Several staff members could not recall whether a narcotic sheet was present for the resident, and there was no verified paper trail for the delivery, only an electronic signature. The lack of a consistent and documented process for counting and reconciling controlled substances during shift changes and resident transfers contributed to the inability to account for the missing medication. Observations and interviews further indicated that the facility's procedures for handling and documenting controlled substances were not consistently followed. Staff described varying practices regarding narcotic counts, storage, and documentation, and some were unaware of specific policies such as the clear bag policy. The facility's own policy required detailed recordkeeping and reconciliation of controlled substances, but these procedures were not adhered to, resulting in the unaccounted loss of a controlled medication for the resident.