Failure to Secure and Monitor Controlled Substances Resulting in Drug Diversion
Penalty
Summary
The facility failed to maintain an adequate system for storing and monitoring controlled substances, resulting in missing medications for multiple residents. The investigation revealed that the facility used loose-leaf, unnumbered paper in a binder to track controlled drugs, which did not correspond to the medication cards and allowed for easy removal of both medication and records. This lack of a secure and detailed tracking system enabled discrepancies to go undetected, and several residents were found to be missing significant quantities of their prescribed medications, including Seroquel, Alprazolam, Mirtazapine, Tramadol, and Norco. The initial missing medication was identified when a resident ran out of Seroquel 14 days earlier than expected, and further review uncovered additional losses affecting other residents. Staff interviews indicated that a specific nurse was the common factor in the missing medication cases, yet this nurse continued to work and sign for narcotics for over two months after the first discrepancy was identified. The consultant pharmacist was not promptly informed of the diversion and did not participate in the investigation or monitor narcotics reconciliation logs. The facility's policy required immediate notification and monitoring in the event of discrepancies, but these procedures were not followed, and the local police and board of nursing were not contacted until months after the initial discovery of missing medications.