Failure to Investigate Suspected Drug Diversion and Medication Discrepancies
Penalty
Summary
The facility failed to conduct a thorough investigation into suspected drug diversion involving four residents who were prescribed and administered narcotic pain medications. For these residents, discrepancies were found between the electronic medication administration records (eMAR), narcotic sign-out sheets, and the physical count of medication tablets. In several cases, doses were documented as given at times inconsistent with physician orders, and some doses were signed out but not properly accounted for in the medication count. For example, one resident's narcotic card showed fewer tablets remaining than should have been present, and another resident's medication card was not provided for verification. Staff interviews revealed confusion and lack of clarity regarding who administered certain doses, and in one instance, a nurse admitted to removing medication from the card for another staff member to administer, which she acknowledged was inappropriate. The Corporate Nurse Consultant, upon being informed of missing medications, reviewed medication carts and narcotic count books but did not reconcile narcotic sheets with the eMAR or report the discrepancies to regulatory agencies. No medication reconciliation was performed for certain doses, and the investigation did not include a comparison of narcotic sheets with the medication administration records. The facility's failure to properly investigate and reconcile these discrepancies led to the deficiency cited in the report.