Failure to Accurately Account for Controlled Medications and Maintain Proper Records
Penalty
Summary
The facility failed to maintain a consistent and accurate process for counting and accounting for controlled medications, resulting in a card of Oxycodone/acetaminophen (Percocet) prescribed to a resident becoming unaccounted for. The resident in question had a history of cerebral palsy, stroke, and polyneuropathy, and was receiving both scheduled and as-needed opioid medications for chronic pain. The care plan directed staff to administer analgesics as ordered by the physician. Despite these directives, staff were unable to account for a card of Percocet with 12 administrations remaining, as well as the associated controlled drug record sheet and the total count sheet for the medication cart. Multiple staff interviews revealed inconsistencies and confusion in the medication counting process. The DON confirmed that two cards of Percocet had been combined onto a single count sheet, contrary to facility expectations that each card should have its own record. On the day the discrepancy was discovered, staff noted that the count sheet and the partial card of Percocet were missing, and the count sheet for the cart was also unaccounted for. Staff involved in the medication counts provided conflicting accounts regarding the number of items in the cart and the process for cosigning count sheets. One staff member denied signing a count sheet for the Percocet, noting differences in ink and signature style, while another staff member was reported to have been defensive when questioned about the missing items and left the facility before the DON arrived. Further observations found that a discontinued controlled medication (Nayzilam) remained in the medication cart weeks after its discontinuation, and there was confusion among staff regarding how to count certain medications, such as whether a box of nasal spray should be counted as one or two items. The process for removing discontinued medications was not consistently followed, as staff were unaware that the medication was still present in the cart. These lapses in medication management and documentation contributed to the inability to account for controlled substances as required by professional standards.