Failure to Maintain Controlled Substance Accountability Resulting in Missing Narcotics
Penalty
Summary
The facility failed to maintain proper control and accountability of controlled substances, specifically Morphine, for two residents. According to the facility's policy, staff were required to keep accurate declining inventory records, reconcile counts at each shift change, and immediately report and investigate any discrepancies. However, a discrepancy was discovered when a total of 7 milliliters of Morphine was found missing from the personal supplies of two residents. The missing amounts included 3 milliliters from one resident and 4 milliliters from another, with one of the bottles having a tampered seal and never having been used by the resident. One resident involved had diagnoses including congestive heart failure, dilated cardiomyopathy, and COPD, and was cognitively intact at the time of the incident. This resident reported using Morphine primarily for shortness of breath and was unaware of any missing doses. The other resident had a history of pneumonia and chronic respiratory failure with hypoxia and was severely cognitively impaired. This resident no longer had an active order for Morphine at the time of the incident. The events leading to the deficiency included a report that an LPN was suspected of working while impaired. When asked to participate in a narcotics count, the LPN handed over their keys and left the facility. An immediate recount by the DON and other nurses revealed the discrepancies in the Morphine counts. The incident was reported to the police, and it was noted that the Morphine bottles had been tampered with and secured to prevent further access.