Failure to Safeguard Narcotic Medications Leads to Missed Pain Doses
Penalty
Summary
The facility failed to protect residents from misappropriation of their narcotic medications, resulting in two residents missing physician-ordered pain medications. For one resident with severe cognitive impairment, osteoarthritis, chronic kidney disease, and diabetes, the medication administration record showed that oxycodone was unavailable for several days, and the resident was instead given Tylenol for pain. The controlled drug record indicated that a significant number of oxycodone doses were received from the pharmacy, but the last dose was signed out several days before the medication ran out, and the delivery sheet showed more doses were delivered than were accounted for in the medication cart. Another resident, also with severe cognitive impairment and multiple serious diagnoses including malignant neoplasm, diabetes, hemiplegia, and cirrhosis, was prescribed Norco for pain. The medication administration record documented that Tylenol was given when Norco was not available. The controlled drug record and pharmacy delivery sheet indicated that more doses were delivered than were present in the medication cart, and the resident missed routine doses of their narcotic medication. Facility investigation revealed that full sheets of narcotic medications had gone missing from the medication cart, and that required shift-to-shift narcotic counts were not consistently performed or documented. Interviews with nursing staff and facility leadership confirmed that medication count sheets and narcotic medications were missing, and that the lack of consistent shift counts made it impossible to determine the exact number of missing doses. Both residents received alternative pain medication while the facility worked to obtain new orders and refills from the pharmacy. The facility's own policy required that all controlled substances be counted by two nurses at each shift change, but this procedure was not followed, contributing to the loss of medications.