Failure to Secure and Store Narcotics Results in Missing Medications
Penalty
Summary
The facility failed to store unused narcotic medications in accordance with its own policy and accepted professional standards, resulting in the loss of controlled substances prescribed to two residents. For one resident, a physician had ordered Oxycodone 5 mg every four hours as needed for pain, and after the resident was discharged to the hospital, the remaining doses were counted by two nurses and placed in a pharmacy tote with a numbered zip lock tag. This tote was then stored in the Unit Manager's office, which was not always locked and accessible to several staff members. The exact duration the tote remained in the office before being sent to the pharmacy was unknown, and when the pharmacy received the tote, the medication was missing, though the seals were intact. For another resident, who had a physician's order for Oxycodone 5 mg three times daily for pain, the remaining medication was placed by the night shift supervisor in an unlocked desk drawer in the same office. The office was sometimes locked, but multiple staff had keys, and the medication was not secured in a double-locked compartment as required. During an investigation into the missing narcotics for the first resident, it was discovered that the medication for the second resident was also missing, with only the narcotic count form found in the unlocked drawer. Interviews with nursing staff and the DON confirmed that the process for storing and returning narcotics was not consistently followed, and staff were unaware that medications should not be left in unsecured locations. The facility's policy required all narcotic medications to be stored under double lock in a designated cabinet or safe, but this was not adhered to, resulting in the loss of a significant number of controlled medication doses for both residents.