Failure to Maintain Accurate Narcotic Logs and Proper Destruction of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed morphine for pain management related to cancer and a bone fracture. The resident had orders for morphine 15 mg to be given as half a tablet (7.5 mg) three times daily, with an additional as-needed order. However, discrepancies were found between the medication administration record (MAR) and the narcotic log, with the MAR documenting 19 doses administered and the narcotic log showing only 17 doses signed out. Staff interviews revealed that doses were sometimes documented as given in the MAR when they were not actually administered, and that the timing of administration did not always match the records. Further investigation showed that staff were saving the unused half-tablets of morphine instead of properly destroying them with a witness, as required by facility policy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were unaware that this practice was occurring until it was brought to their attention. The facility's narcotic records and morphine card were not updated to reflect the correct dose after the physician's order was changed, and staff did not use correction stickers or obtain a new dose card from the pharmacy as required. Additionally, there were missing signatures on the narcotic record, indicating that proper witnessing of drug destruction did not occur. Competency checks for medication aides (MAs) were on file, but the MAs admitted to documenting doses as given when they were not, and to saving half-tablets in the medication cart. The DON confirmed that staff should have contacted the pharmacy and physician to obtain the correct dose and documentation, and that two staff members were required to witness drug destruction. The facility's policies on pharmacy services and controlled medication management were not followed, resulting in inaccurate narcotic logs and improper handling of controlled substances.