Delayed Removal of Narcotic Medication After Resident Death
Penalty
Summary
The facility failed to ensure the timely removal of a narcotic medication, Dilaudid, from the medication cart following the death of a resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome. The resident had a physician's order for Dilaudid to be administered as needed for severe pain, and the medication was last given prior to the resident's death. Despite the resident being pronounced dead, the Dilaudid remained in the medication cart for 20 days before being removed and returned to the office, as documented in the pharmacy Controlled Substance Disposition Record. Interviews with nursing staff and administrative personnel revealed that the process for removing narcotics after a resident's discharge or death was not consistently followed. Staff reported delays in removing narcotics due to lack of prioritization and refusal by the previous Director of Nursing Services (DNS) to co-sign for removal. The facility's policy directed that discontinued medications should be removed from the resident's supply once an order is received, but this was not adhered to in this case, resulting in the narcotic remaining accessible in the medication cart well beyond the resident's death.