Failure to Account for and Properly Destroy Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were accurately accounted for and destroyed appropriately for one resident. According to facility policy, all Schedule II medications and those with potential for abuse or diversion should be tracked using a declining inventory record, and incoming and outgoing nurses are required to count these medications at each shift change. In this case, a card containing 13 tablets of oxycodone was delivered for a resident with diagnoses including peripheral vascular disease, osteoporosis, and atrial fibrillation. The RN supervisor signed for the medication, but the agency nurse who received it did not sign it into the controlled drug tracking log and instead subtracted the card, stating the order was discontinued. The medication was not placed into the locked medication cart, and the discrepancy was only discovered when the resident requested the medication and it could not be located. Further review revealed that the agency nurse also signed for additional narcotics that were to be destroyed, but destruction forms were not completed, and the facility was not following the required process of having two licensed staff destroy medications. Interviews with facility leadership confirmed that the facility failed to verify that narcotics were being disposed of appropriately and that controlled substances were not properly accounted for or destroyed as required by policy.