Failure to Follow Policy for On-Site Destruction of Narcotics
Penalty
Summary
The facility failed to follow its own policy regarding the destruction of unused narcotics. According to the facility's undated policy, the destruction of drugs must be conducted on the premises and witnessed by the consultant pharmacist along with either an agent of the State Board of Pharmacy, the facility administrator, or the director of nursing services. However, review of the Narcotic Destruction Logs revealed that while the logs listed residents' names, medications, amounts of narcotics remaining, nurses' initials, and reasons for destruction, they did not document the actual destruction of the narcotics as required by policy. Interviews with the Assistant Director of Nurses (ADON), the Administrator, and the Consultant Pharmacist confirmed that narcotics belonging to residents who had expired or been discharged were not destroyed on the facility premises. Instead, a collection process was used, and the drugs were processed off-site. Both the ADON and the Administrator were unaware that the facility's practice did not align with its written policy, and the Consultant Pharmacist was also not aware of the discrepancy between the policy and the actual process for narcotic destruction.