Failure to Account for Controlled Substances Due to Lapses in Medication Handling and Inventory Procedures
Penalty
Summary
The facility failed to maintain accountability for 17 Percocet tablets, a Schedule II controlled substance, prescribed to a resident with muscle weakness and spina bifida. The medication was ordered to be discontinued, but at the time of discontinuation, 17 tablets were unaccounted for. The medication administration record showed the last dose was given on one date, but additional doses were documented as administered after that date. The narcotic inventory sheets, which are supposed to be signed and checked at each shift change, did not indicate any discrepancies, and the process for handling discontinued medications was not consistently followed. Multiple interviews with nursing staff revealed lapses in the required procedures for controlled substance inventory and handoff. Nurses did not consistently perform or document narcotic counts together at shift changes, and there was confusion about the presence and handling of the discontinued Percocet bubble pack. At one point, the medication cart key was left unattended in a drawer, contrary to facility policy, which increased the risk of unauthorized access to controlled substances. Staff members gave conflicting accounts regarding whether the discontinued medication and its accompanying documentation were present during inventory counts. Facility policies require that controlled substances be stored under double lock, that only authorized personnel have access, and that a physical inventory be conducted and documented by two licensed nurses at each shift change. The policies also state that any discrepancies must be reported immediately to the director of nursing. In this case, these procedures were not consistently followed, resulting in the unaccounted loss of 17 Percocet tablets and a breakdown in the facility's controlled substance accountability system.