Failure to Prevent Misappropriation of Controlled Substance
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's prescribed controlled substance, specifically a narcotic pain medication. The incident involved a resident with diagnoses of metabolic encephalopathy and end stage renal disease, who required staff assistance with activities of daily living and had intact cognition. The issue was discovered after a pharmacy refill request for the resident's pain medication was denied due to being too early, prompting further investigation by the Director of Nursing (DON). Upon review, it was found that two sleeves of 30 Norco 10/325 pills each had been delivered to the facility, but only one sleeve was accounted for on the narcotic count sheet. The count sheet for the missing medication had a hand-written identification label instead of the standard pharmacy-provided sticker. By cross-referencing pharmacy records, handwriting, and staff schedules, it was determined that the discrepancy occurred while the medications were under the care and control of an LPN. The resident received pain medication from the facility's emergency backup supply during this period. The facility's investigation did not uncover evidence supporting alternative explanations for the missing medication. Audits of other residents' narcotics did not reveal further discrepancies. The facility's policies require controlled substances to be stored securely and for any discrepancies in controlled medication counts to be reported and investigated immediately, but these procedures were not effectively followed in this instance, resulting in the misappropriation of the resident's medication.