Failure to Timely Remove and Return Discontinued Controlled Medication Resulting in Diversion
Penalty
Summary
The facility failed to implement effective systems for the timely removal and return of discontinued controlled medications, resulting in the diversion of a controlled substance prescribed to a resident. According to the facility's policy, discontinued medications are to be identified and removed from the medication supply in a timely manner, in accordance with state and federal regulations. However, after a physician discontinued an order for Oxycodone/Acetaminophen for a resident, the medication card containing 8 tablets remained in the medication cart and was not promptly removed by nursing administration. A review of medication administration records showed that none of the Oxycodone/Acetaminophen doses were administered to the resident before the order was discontinued. The discrepancy was discovered when the DON reconciled the narcotic medications and found that the count was off, with a medication card missing from the cart. The facility's consultant pharmacist confirmed that the medication had not been returned to the pharmacy as required, and that the process for returning discontinued narcotics involved sealing the medication and documenting its disposition, but this process was not followed in this instance. Interviews with facility staff revealed that there was no specific timeframe for removing discontinued medications from the cart, and that two nurses were supposed to verify and sign off on the amount being returned. The lack of adherence to these procedures allowed for the misappropriation of the controlled medication, as the medication card was missing and not accounted for in the return documentation. The incident was substantiated as misappropriation of facility property.