Failure to Accurately Account for Receipt and Disposition of Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically OxyContin ER 10mg, for one resident. The medication was documented as received from the pharmacy, with signatures from both the LVN and the pharmacy driver, but there was no accurate reconciliation or detailed record to confirm the medication was actually received and properly distributed. The process for checking in and distributing controlled substances was inconsistent, with staff unable to verify whether the medication was present or delivered to the correct unit. The resident involved was an adult male with a history of cauda equina syndrome, chronic pain syndrome, a displaced fracture, and benign prostatic hyperplasia. His care plan included scheduled opioid pain medication, and his medication administration record indicated he received pain medication daily. However, interviews with staff revealed uncertainty about the actual receipt and distribution of the OxyContin, with the responsible LVN unable to confirm if the medication was included in the delivery or handed off to the nurse responsible for the resident's unit. There was no documentation or signature from the second LVN to confirm receipt of the medication. Administrative staff, including the ADM and ADON, acknowledged the lack of an accurate process for receiving and reconciling controlled medications. The pharmacy driver also confirmed that, prior to the incident, he did not observe the nurse count in the medications upon delivery. The facility's policy required a controlled medication accountability record to be prepared upon receipt, but this procedure was not followed, resulting in an inability to account for the controlled substance in question.