Failure to Secure and Return Controlled Medication Results in Diversion
Penalty
Summary
The facility failed to maintain effective systems for the return of controlled medications to the pharmacy, resulting in the diversion of a controlled substance for one resident. A resident was discharged from the facility, and 11 tablets of 5 mg oxycodone HCL remained to be returned to the pharmacy. The process for returning these medications was started by a nurse but not completed, and the medication, along with the narcotic count sheet, subsequently went missing from the medication cart. Multiple staff interviews confirmed that the medication and count sheet were present during the morning shift change but were discovered missing during the evening shift narcotic reconciliation. Nursing staff provided conflicting accounts regarding the handling and storage of the controlled medication and associated documentation. One nurse stated she believed she had returned the medication and count sheet to the narcotic drawer but was unsure if she may have inadvertently discarded them. Another nurse reported that the return process for the narcotics had been started but not completed, and that it was the responsibility of all nurses to ensure discontinued or discharged medications were returned to the pharmacy. The Director of Nursing confirmed that the process required completion of a return form, placement of the medication and count sheet in a bag, and transfer to a locked safe in the DON's office, but this process was not followed in this instance. The missing medication and documentation were reported to the Director of Nursing, and an internal investigation was initiated. The police were notified, but the missing items could not be located, and no charges were filed due to lack of evidence. The incident revealed lapses in medication security, incomplete documentation, and failure to follow established procedures for the return of controlled substances, resulting in the loss of a controlled medication and its associated records.