Failure to Investigate and Document Missing Controlled Medications
Penalty
Summary
The facility failed to ensure full investigations were completed to rule out potential misappropriation of controlled medications for four of six sampled residents who had physician-ordered controlled medications. Multiple incidents were identified where controlled substances, including Fentanyl patches, Tramadol, and Xanax, were found to be missing during medication counts between nursing shifts. In each case, staff searched for the missing medications, notified the DON and administrator, and completed incident reports, but there was no documentation of comprehensive investigations to determine the cause of the missing medications or to rule out misappropriation or diversion. Interviews and document reviews revealed that staff were not consistently following established procedures for the destruction of controlled substances, such as Fentanyl patches, and for the verification of narcotic counts at shift changes. There were numerous days where required two-person signatures were missing from narcotic count verification forms across all medication carts. Staff reported frequent distractions during medication passes, which contributed to medication errors and discrepancies in controlled medication counts. Additionally, some staff were unaware of recent education or changes in procedures related to controlled medication administration and destruction. The DON confirmed that investigations into missing medications were limited to interviews with involved staff and that there was no documentation to support that misappropriation had been ruled out. The facility's policies required collaboration with pharmacy staff and thorough documentation during investigations of missing or diverted medications, but these steps were not followed. Furthermore, there was no evidence that the pharmacy was involved in the investigation process, and required audits and staff education on drug diversion and misappropriation were not documented as completed.