Failure to Accurately Account for and Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the controlled medication Clonazepam 0.125 mg. An incorrect narcotic count was discovered during a shift change, revealing that 11 tablets were missing from the resident's supply. The discrepancy was identified when the oncoming and off-going nurses counted the medication together, and both denied taking the pills. The count had been correct the previous night, and the missing tablets were never recovered. The medication administration records confirmed the loss, showing a decrease in the tablet count between the two shifts. Observations of the medication counting process revealed that the off-going nurse typically only verified the count sheet rather than directly observing the physical count of medications, while the oncoming staff performed the count. This practice did not ensure both parties verified the actual medication count, and the process was not consistently followed as intended. The nurse involved stated she had not been instructed to perform the count differently and acknowledged that not verifying the count could lead to missing or stolen medications. Additionally, the nurse did not perform a count immediately after administering controlled medications during her shift, instead waiting until the end of the shift. The investigation into the missing medication was limited to interviewing and drug testing the two nurses involved, with no interviews conducted with the resident, her responsible party, or other residents at the time of the incident. The resident later confirmed she was not interviewed about the missing medication and denied missing any doses or experiencing increased anxiety. Facility leadership acknowledged that no other staff or residents were interviewed during the initial investigation, and the responsible party was not notified until several months later.