Failure to Maintain System for Monitoring and Tracking Stored Narcotics
Penalty
Summary
The facility failed to implement an effective system to monitor and track stored narcotics, which had the potential to affect all 16 residents prescribed Schedule II-V medications. Observations and interviews revealed that the narcotic record index pages in both the West and East medication carts were not updated beyond page 55, despite the narcotic books containing documentation through page 127. Staff confirmed that the index pages were no longer used to log new medications or to guide shift change narcotic counts. Instead, staff relied on memory and routine to identify which medications should be present, without a formal list or tracking method. During a medication cart narcotic count, nurses verified the number of doses by matching the medication card with the narcotic book, but did not reference an updated index or comprehensive list. The DON acknowledged that there was no refined system or alternative method in place to account for every narcotic in the facility. Additionally, a handwritten document listing controlled medications did not include corresponding narcotic book page numbers, further limiting the ability to accurately track and monitor controlled substances. The facility's policy required safeguards to prevent diversion, but these were not effectively implemented.