Failure to Secure and Document Receipt of Controlled Medication
Penalty
Summary
The facility failed to ensure the secure handling and storage of a resident's controlled medication, specifically 60 tablets of oxycodone-acetaminophen, which were delivered by the pharmacy. The medication was received by a registered nurse (RN 2), who handed both the narcotic record sheet and the medication to another nurse (RN 1) to be placed in the medication cart. However, there was no documentation or record that the medication was added to the cart, and subsequent counts by staff revealed that the medication and its record sheet were missing. Multiple staff statements and interviews confirmed that the medication was not observed in the cart during shift changes, and a thorough search of all medication carts and the medication supply room failed to locate the missing narcotics. Video surveillance footage showed RN 2 handing the medication and record sheet to RN 1, who placed them in a folder or envelope on top of the medication cart, but the footage did not show what happened to the items afterward. RN 1 did not return to work the following day and was unresponsive to attempts to obtain a statement regarding the missing medication. The resident for whom the medication was intended had diagnoses including stroke, heart disease, and kidney disease, and was prescribed oxycodone-acetaminophen for pain management. Despite the missing medication, the resident did not report pain or missed doses, as there was still a supply available. The incident was reported to the appropriate authorities, and the facility's policy required controlled substances to be stored under double lock and properly documented upon receipt, which was not followed in this case.