Failure to Properly Destroy and Document Partial Dose of Controlled Substance
Penalty
Summary
A deficiency occurred when a partial dose of a controlled substance, oxycodone, was not destroyed and recorded in the presence of two licensed personnel as required by facility policy and federal regulations. A resident with a history of cocaine abuse, opioid use, and major depressive disorder, who was cognitively intact, had a physician's order for oxycodone 5 mg every six hours as needed for pain. On one occasion, the facility ran out of the 5 mg tablets, and an LPN obtained a one-time order to administer half of a 10 mg oxycodone tablet. The LPN split the tablet, administered half to the resident, and saved the remaining half in a medication cup stored in the narcotics lock box for later use, rather than destroying it as required. The Controlled Drug Receiving Record/Disposition Form showed that the half tablet was administered, but the record lacked the administering staff member's signature for the initial dose. The remaining half tablet was later administered and signed off by staff on the following shift. The LPN involved admitted to saving the half tablet for the next shift and forgetting to complete the narcotic record sheet. Facility policy, provided by the Nurse Consultant, specified that unused partial tablets must be destroyed and recorded in the presence of two licensed personnel, which was not followed in this instance.