Failure to Safeguard and Accurately Document Controlled Substances
Penalty
Summary
The facility failed to safeguard controlled substances, resulting in the misappropriation of a resident's medication. A resident with multiple medical conditions, including diabetes, fractures, heart failure, and a urinary tract infection, was prescribed oxycodone. When staff attempted to reorder the medication, the pharmacy reported it was too soon for a refill, revealing that 60 tablets had already been delivered and registered in the facility's narcotic count. Despite a comprehensive search, the medication and its control sheet could not be located, and the facility was unable to determine who or when the medication was misappropriated. The incident was identified when the pharmacy denied the refill request, and the attending physician was notified immediately. Further observations during the survey revealed ongoing issues with the documentation and reconciliation of controlled substances. During medication reconciliation, discrepancies were found between the number of tablets recorded on the Controlled Drug Administration Record (CDR) and the actual number of tablets present for two residents. In both cases, a nurse admitted to administering the medication but forgetting to sign it out on the CDR. Additionally, inconsistencies were found between the number of controlled medication cards and the corresponding count sheets, which were not identified during shift change reconciliations. Interviews with nursing staff confirmed a lack of awareness regarding unidentified controlled drugs being stored in the medication lock box and acknowledged continued concerns with documentation and reconciliation of controlled substances. The facility's policy prohibits misappropriation of resident property, but the failure to maintain accurate records and perform thorough shift change counts contributed to the deficiency.