Failure to Document Destruction of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to the facility's policy, the destruction of controlled or narcotic medications, such as Fentanyl patches, must be witnessed and signed by two licensed nurses, with the amount destroyed logged on the Control Drug Record. Review of the clinical records and controlled drug count logs for a cognitively impaired resident who routinely received opioid pain medication revealed that, although Fentanyl patches were administered and logged as given, there was no documented evidence that two staff members signed for the destruction of the old patches after removal on multiple occasions. Further review of the Medication Administration Record and controlled drug count record confirmed that the required dual signatures for the destruction of Fentanyl patches were missing for several dates. An interview with the Director of Nursing corroborated that the two witness signatures were not present for the destruction of the patches as required by policy. This failure to document the destruction of controlled substances in accordance with facility policy and regulatory requirements resulted in a deficiency related to pharmacy services and recordkeeping.
Plan Of Correction
Resident 25 assessed with no noted concerns with his pain and/or his pain medications. Any resident having a physician order to receive a narcotic pain patch has the ability to be affected by this alleged deficient practice. A whole house facility audit was completed to ensure the Controlled Drug Count Records of residents who recently received narcotic pain patches have recorded documentation of two licensed nurse witness signatures for the destruction of the narcotic pain patches when removed from these residents. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Narcotic and Controlled Substance Policy and Procedure regarding maintaining accountability for controlled medications, including the importance of witnessing and recording the destruction of any narcotic by two licensed nurses on the resident's Controlled Drug Record, including the removal of narcotic pain patches. The Director of Nursing/Designee will complete random audits of residents receiving narcotic pain patches, including Fentanyl, to ensure accurate documentation of the witnessing and recording of the witnessed destruction of the narcotic pain patch by two licensed nurses on the resident's Controlled Drug Record when the patch was removed. These audits will be conducted weekly for twelve weeks, then monthly for six months until substantial compliance is noted. The Director of Nursing will conduct a thorough investigation of audit findings of any noted discrepancies and/or missing witness documentation of narcotic/controlled medication destruction to rule out any resident misappropriation and to ensure narcotic/controlled drug medication accountability. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings, times nine months, for results, areas of improvement, and/or continuation of audits.