Failure to Obtain Witness Signature During Controlled Medication Destruction
Penalty
Summary
The facility failed to ensure the proper disposal of controlled medications by not obtaining a witness signature on the narcotic sheet during the destruction of medications for nine residents. Specifically, the Assistant Director of Nursing (ADON) was found to have destroyed tablets of Hydrocodone-APAP, Tramadol, and Acetaminophen-Codeine without a witness present, as required by facility policy. Record reviews showed that for each instance, the narcotic sheets lacked the required witness signature, despite the destruction of the medication being documented. Interviews with staff, including other ADONs and Licensed Vocational Nurses (LVNs), confirmed that the standard practice was to always have a witness present when destroying controlled substances. The Director of Nursing (DON) acknowledged that instructions were given to audit and destroy medications with damaged blister packs, but it was discovered that the ADON destroyed these medications without a witness. The facility's policy clearly states that two licensed nurses must be present and sign the controlled substances record when a controlled medication is destroyed. The residents involved had active or discontinued orders for controlled pain medications, and the destruction events occurred over several months. The lack of a witness signature on the narcotic sheets was consistently observed across multiple residents and medications, indicating a pattern of non-compliance with established procedures for controlled substance disposal.