Failure to Safeguard Residents' Narcotic Medications
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed narcotic medications, specifically Oxycodone. Both residents had chronic pain and were moderately cognitively impaired, with physician orders for Oxycodone—one as needed and one scheduled via feeding tube. During a routine audit, it was discovered that two cards of Oxycodone, totaling 84 tablets, and the second page of the narcotic count sheet were missing from a medication administration cart assigned to a specific hall. The discrepancy was identified during a narcotic process audit by the DON, who found that the medications and documentation were not present as required. The investigation revealed that the last nurse assigned to the cart did not notice any discrepancies during the shift change narcotic count, which was conducted and signed off by both the outgoing and incoming nurses. No pain issues were reported for the residents during the relevant shifts, and the medication administration records indicated that one resident did not require PRN Oxycodone, while the other received her scheduled dose. Despite the required procedures for narcotic counts and documentation at each shift change, the missing medications were not detected until the audit, and no staff reported any issues or suspicious behavior prior to the discovery. Interviews with nursing staff, the pharmacy consultant, and the medical director confirmed that the narcotic count was believed to be correct at the time of shift changes, and no one could account for the missing medications. The facility's process required two nurses to complete narcotic counts at each shift change and to report any discrepancies immediately, but the loss of the narcotics and documentation was not identified until after the fact. The investigation was unable to determine how the medications were removed or by whom, resulting in a failure to safeguard the residents' property as required.