Failure to Ensure Accurate Accountability and Protection of Resident's Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and pain due to internal orthopedic devices was not properly protected from the misappropriation of their controlled medication. The facility's policies required that the nurse who prepares and administers a controlled substance must immediately document the administration on both the controlled substance log and the Medication Administration Record (MAR), ensuring accurate accountability of all controlled drugs at all times. However, on the date in question, the controlled drug record showed that an LPN signed out four doses of oxycodone for the resident, but the MAR only reflected two administrations, and a medication error report later confirmed that an extra dose was given. Interviews with staff revealed that controlled substances were kept locked and that a count was performed at each shift change. On the shift in question, the oncoming LPN found that several residents were unable to receive their pain medication because the log indicated the medications had already been dispensed, even though the MAR did not reflect this. The oncoming nurse reported the discrepancy to the DON, who initiated an investigation, including a full narcotic count and MAR review. The investigation determined that an extra dose of oxycodone had been administered to the resident, and the resident was assessed for adverse reactions, with none found. Further review showed that the facility was unable to provide requested shift change controlled substance count sheets for several dates, and the LPN involved was no longer employed at the facility and could not be interviewed. The administrator could not confirm whether the resident was charged for the unaccounted-for medication. The deficiency was attributed to the failure to ensure that the controlled substance log and MAR matched for each administration, resulting in improper documentation and potential misappropriation of the resident's medication.