Failure to Maintain Accurate Narcotic Counts and Documentation
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt, disposition, and reconciliation of controlled drugs, specifically narcotics, as required by policy and regulation. On one unit, narcotics were not counted by two licensed staff members at the end of a shift, resulting in the discovery that twenty Oxycontin extended-release 10 mg tablets prescribed for a resident were missing. Documentation revealed that the required dual-nurse narcotic count was not performed, and the controlled medication record did not align with the medication administration record, indicating inconsistencies in documentation and administration practices. The resident involved had diagnoses including fibromyalgia, chronic pain syndrome, and anxiety disorder, and was cognitively intact according to the Minimum Data Set. The resident's medication order for Oxycontin was not properly accounted for, with the last documented administration showing 20 pills remaining, but the next shift discovering the entire blister pack missing. Interviews with nursing staff revealed that narcotic counts were either not performed together as required or were not performed at all, with some staff admitting to taking each other's word rather than conducting the count in person. Signature sheets for narcotic counts across multiple units were inconsistently completed, with missing signatures from both oncoming and outgoing nurses on several shifts. Further review and interviews indicated that this was not an isolated incident, as narcotic count signature sheets on all six nursing units showed similar deficiencies in documentation. Some staff reported receiving education on proper narcotic handling and documentation, while others did not recall such training. Despite the facility's policy requiring dual-nurse counts and immediate reporting of discrepancies, these procedures were not consistently followed, leading to unaccounted controlled substances and incomplete records.