Failure to Ensure Proper Destruction and Documentation of Controlled Substances
Penalty
Summary
The facility failed to ensure accurate documentation and accountability for the destruction of controlled substances. During an observation in the Director of Nursing's office, a locked cabinet was found containing medications to be destroyed. Review of the Controlled Medication Destruction Log (MDL) for March and April revealed that entries for several controlled substances, including oxycodone, lorazepam, morphine, and hydrocodone, were not properly dated or signed, and lacked the required involvement of a licensed pharmacist. The Assistant Director of Nursing was unable to clarify these entries, and the Pharmacy Consultant confirmed she had not participated in the destruction of the medications in question. The nurse had incorrectly documented the destruction of narcotics without proper verification, and no concurrent destruction had occurred for those entries. The facility's policy and procedure required that the destruction of controlled substances be conducted in the presence of both a pharmacist and a registered nurse, with appropriate documentation including signatures of both witnesses and detailed information about the medication and its disposal. The reviewed records did not meet these requirements, as the destruction was not witnessed by a pharmacist and the necessary documentation was incomplete or missing. This failure resulted in a lack of accountability for the management and destruction of controlled medications.