Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from misappropriation of controlled medications. The incident involved a resident who had an active order for Oxycodone HCL 5 mg, with 120 tablets delivered to the facility. The medication was signed in by two nurses and the pharmacy courier, but a subsequent audit revealed that one card of 30 tablets and its corresponding declining count sheet were missing from the medication cart and narcotic records. Multiple shift-to-shift controlled substance counts were documented as correct, but the discrepancy was discovered during a narcotic audit by the Assistant Director of Nursing (ADON), who noted inconsistencies between the electronic Medication Administration Record (eMAR) and the physical count sheets. Staff interviews and written statements indicated that the process for receiving and storing controlled substances involved two nurses and the pharmacy courier counting and signing for the medications. However, it was revealed that the nurses did not always physically verify the placement of the medications on the correct cart. The missing medication card and count sheet were not immediately detected, as shift-to-shift counts appeared correct, and the medication cards were sometimes used out of order. The ADON's investigation found that the number of narcotic cards and count sheets matched, but one card and its sheet could not be located after a thorough search. Further investigation led to the removal of a nurse from staffing after she refused to provide a statement or submit to a drug screen. The Director of Nursing (DON) and other staff conducted a full audit and investigation, confirming that no other residents' medications were missing and that all other counts were correct. The incident was reported to the facility administrator, and the nurse involved was reported to the Board of Nursing. The deficiency was substantiated by the inability to account for the missing controlled medication and the associated documentation.