Failure to Account for Controlled Substances Due to Inadequate Reconciliation Procedures
Penalty
Summary
The facility failed to ensure an accurate reconciliation and accounting of all controlled substances for a resident who was admitted with multiple diagnoses, including chronic ulcers, diabetes with foot ulcer, rheumatoid arthritis, and spondylolisthesis. The resident had a physician's order for Oxycontin 10 mg, to be administered twice daily for chronic pain. On a specified date, the pharmacy delivered 30 tablets of Oxycontin for the resident, but these tablets could not be accounted for during a subsequent review. Medical record review showed that the resident was discharged home with his wife and was sent with medications for the rest of the weekend. However, the day after discharge, the facility discovered that the full supply of 30 Oxycontin tablets delivered earlier was missing. The facility was unable to determine the whereabouts of the medication, and the discrepancy was identified through inconsistencies between narcotic proof of use sheets and narcotic skids. Interviews with facility staff revealed that two nurses failed to follow protocol by transferring narcotic keys without conducting a required count of the controlled substances. This lapse in procedure contributed to the inability to reconcile the controlled drug records and maintain an accurate account of the medication, as required by facility policy and federal regulations.