Expired Controlled Medication Administered Due to Inadequate Reconciliation
Penalty
Summary
The facility failed to ensure proper reconciliation and administration of controlled drug medications, specifically regarding the handling of expired narcotic medication for one resident. During observation and record review, a surveyor found that an expired Oxycodone 5mg tablet card was present in the narcotic lock box and had been administered to the resident after its expiration date. The narcotic count log and controlled drug receipt/record/disposition form confirmed that the expired medication was given by a registered nurse. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expired medication was administered and that the expectation is for staff to verify both counts and expiration dates during the two-person handoff at each shift change, as well as during medication administration. Review of the resident's medical record showed a physician's order for Oxycodone 5mg for pain management, and the medication administration record indicated that the expired medication was given when the resident reported a pain level of 5.