Failure to Secure and Account for Narcotic Medications After Resident Discharge or Death
Penalty
Summary
The facility failed to maintain effective systems and safeguards to prevent drug diversion, specifically regarding the handling and security of narcotic medications for two residents. In the first case, a resident with diabetes and diabetic neuropathy, who was cognitively intact and receiving opioid medications, was discharged to the hospital. After discharge, 45 doses of Oxycodone 5 mg prescribed to the resident were found to be missing. Nursing staff reported counting and placing the medication in a pharmacy tote, sealing it, and leaving it in the Unit Manager's office for pharmacy pickup. However, the medication was not present when the pharmacy received the tote, despite the correct documentation and seals being in place. The tote had been left in an office accessible to multiple staff members, and it was unclear how long it remained there before being sent to the pharmacy. In the second case, another cognitively intact resident with lung cancer, who was also receiving opioid medications, died in the facility. After the resident's death, a medication card containing 30 doses of Oxycodone 5 mg was placed in an unlocked desk drawer in the Unit Manager's office by the night shift supervisor. The office was locked, but several staff members had access to it. The medication was not secured under double lock as required, and the doses were later found to be missing. The narcotic count form for the medication was discovered in the unlocked drawer, but the medication itself was unaccounted for. Interviews with nursing staff and the pharmacist confirmed that the medications were not properly secured and that staff were unaware of the requirement to keep narcotic medications double locked until returned to the pharmacy. The facility's failure to ensure the security of these medications resulted in a total of 75 doses of Oxycodone being unaccounted for, with the medications left in areas accessible to multiple staff members and not properly safeguarded against diversion.